The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 14, 2020
REVIEW ARTICLE

Role of Dental Implant Homecare in Mucositis and Peri-implantitis Prevention: A Literature Overview



Vittorio Checchi1, *, Fabrizio Racca2, Davide Bencivenni1, Laura Lo Bianco2
1 Department of Surgery, Medicine, Dentistry and Morphological Sciences with Transplant Surgery, Oncology and Regenerative Medicine Relevance Unit of Dentistry and Oral-Maxillo-Facial Surgery, University of Modena and Reggio Emilia, Modena, Italy
2 Department of Biomedical and Neuromotor Sciences, Dental School, Department of Periodontology and Implantology, University of Bologna, Bologna, Italy

Abstract

Background:

Correlation between high plaque index and inflammatory lesions around dental implants has been shown and this highlights the importance of patient plaque control. Until now, knowledge of peri-implant home care practices has been based on periodontal devices.

Objective:

The aim of this overview is to identify the presence of scientific evidence that peri-implant homecare plays a role in mucositis and peri-implantitis prevention.

Methods:

Different databases were used in order to detect publications reflecting the inclusion criteria. The search looked into peri-implant homecare studies published from 1991 to 2019 and the terms used for the identification of keywords were: Dental implants, Brush, Interproximal brushing, Interdental brushing, Power toothbrush, Cleaning, Interdental cleaning, Interspace cleaning, Flossing, Super floss, Mouth rinses, Chlorhexidine. The type of studies included in the selection for this structured review were Randomized Clinical Trials, Controlled Clinical Trials, Systematic Reviews, Reviews, Cohort Studies and Clinical cases.

Results:

Seven studies fulfilled all the inclusion criteria: 3 RCTs, one Consensus report, one cohort study, one systematic review and one review. Other 14 studies that partially met the inclusion criteria were analyzed and classified into 3 different levels of evidence: good evidence for RCTs, fair evidence for case control and cohort studies and poor evidence for expert opinion and case report.

Conclusion:

Not much research has been done regarding homecare implant maintenance. Scientific literature seems to show little evidence regarding these practices therefore most of the current knowledge comes from the periodontal literature. Manual and powered toothbrushes, dental floss and interdental brushes seem to be useful in maintaining peri-implant health. The use of antiseptic rinses or gels does not seem to have any beneficial effects.

It can be concluded that to better understand which are the most effective home care practices to prevent mucositis and peri-implantitis in implant-rehabilitated patients, new specific high evidence studies are needed.

Keywords: Dental implant, Home care maintenance, Mucositis, Peri-implantitis, Literature overview, Inflammatory lesions.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 470
Last Page: 477
Publisher Id: TODENTJ-13-470
DOI: 10.2174/1874210601913010470

Article History:

Received Date: 22/08/2019
Revision Received Date: 30/10/2019
Acceptance Date: 05/12/2019
Electronic publication date: 31/12/2019
Collection year: 2019

© 2019 Checchi et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Surgery, Medicine, Dentistry and Morphological Sciences with Transplant Surgery, Oncology and Regenerative Medicine Relevance, Unit of Dentistry and Oral Maxillofacial Surgery, Restorative Dentistry Section, University of Modena and Reggio Emilia, Via del Pozzo, 71 - 41124 Modena, Italy; Tel: +39 059 4224314;
Email: vittorio.checchi@unibo.it






1. INTRODUCTION

Oral rehabilitation with dental implants is a widely used technique to substitute teeth in partially or totally edentulous patients. Since dental implants are a biocompatible prosthetic device implanted in living bone and rehabilitated to function in the oral environment, their surrounding tissue conditions can change overtime [1Ong CT, Ivanovski S, Needleman IG, et al. Systematic review of implant outcomes in treated periodontitis subjects. J Clin Periodontol 2008; 35(5): 438-62.
[http://dx.doi.org/10.1111/j.1600-051X.2008.01207.x] [PMID: 18433385]
, 2Misch CE, Perel ML, Wang HL, et al. Implant success, survival, and failure: The International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent 2008; 17(1): 5-15.
[http://dx.doi.org/10.1097/ID.0b013e3181676059] [PMID: 18332753]
].

After implant insertion and Osseo integration, implant complications can be due to loss of surrounding tissues, such as oral mucosa and supporting bone, or mechanical issues affecting itself or its components. Implant fracture, due to metal fatigue, can be caused by material defects, design or by prosthetic rehabilitation unfitting [3Sánchez-Pérez A, Moya-Villaescusa MJ, Jornet-García A, Gomez S. Etiology, risk factors and management of implant fractures. Med Oral Patol Oral Cir Bucal 2010; 15(3): e504-8.
[http://dx.doi.org/10.4317/medoral.15.e504] [PMID: 20038899]
].

Implants overload have often been related to implant failure, but the lack of studies with a high level of evidence, systematic reviews and Randomized Clinical studies (RCT), prevents understanding if this relation is realistic [4Duyck J, Vandamme K. The effect of loading on peri-implant bone: A critical review of the literature. J Oral Rehabil 2014; 41(10): 783-94.
[http://dx.doi.org/10.1111/joor.12195] [PMID: 24889500]
].

However, the failure of an implant can occur not only from a functional point of view, but also from an aesthetic point of view: it is important to provide prosthetic rehabilitations and peri-implant mucosa in harmony with adjacent teeth [5Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 2008; 19(1): 73-80.
[PMID: 17956569]
].

The major problem clinicians have to deal with is the loss of supporting tissues: the peri-implant disease. Peri-implant diseases are defined as inflammatory lesions that develop in tissues surrounding implant rehabilitations and are classified into two main groups: peri-implant mucositis and peri-implantitis [6Heitz-Mayfield LJ. Peri-implant diseases: diagnosis and risk indicators. J Clin Periodontol 2008; 35(8)(Suppl.): 292-304.
[http://dx.doi.org/10.1111/j.1600-051X.2008.01275.x] [PMID: 18724857]
]. The definition of these two conditions was purposed during the IV World Workshop of Periodontology in 2017, in which both were recognized as phlogistic, but while peri-implant mucositis was described as a reversible lesion affecting only the peri-implant mucosa, peri-implantitis was described as a not reversible condition with damage of the supporting bone [7Berglundh T, Armitage G, Araujo MG, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the classification of periodontal and peri-implant diseases and conditions. J Periodontol 2018; 89(Suppl. 1): S313-8.
[http://dx.doi.org/10.1002/JPER.17-0739] [PMID: 29926955]
].

Similarities in periodontal and peri-implant reaction after biofilm accumulation were analyzed, in both animal and human studies, using histological and immunohistochemical techniques. It was demonstrated that after 21 days of absence from oral hygiene procedures, in both natural dentition and dental implant rehabilitation, periodontium and peri-implant mucosa developed signs of inflammation with similar Plaque Index (PI) and inflammatory infiltrate amount [8Zitzmann NU, Berglundh T, Marinello CP, Lindhe J. Experimental peri-implant mucositis in man. J Clin Periodontol 2001; 28(6): 517-23.
[http://dx.doi.org/10.1034/j.1600-051x.2001.028006517.x] [PMID: 11350518]
].

Association between plaque accumulation and clinical inflammation on implants was also analyzed by Ferreira et al. in a cross-sectional study in which the authors tried to identify prevalence and risk factors of peri-implant diseases [9Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects. J Clin Periodontol 2006; 33(12): 929-35.
[http://dx.doi.org/10.1111/j.1600-051X.2006.01001.x] [PMID: 17092244]
]. It was found that healthy implants had low PI and Bleeding on Probing (BoP) scores, and using a multivariate statistical analysis, poor oral hygiene was identified as a risk factor. Among the analyzed population, 64.6% showed peri-implant mucositis and a lower percentage of 8.9% showed peri-implantitis, though prevalence data showed that peri-implant mucositis and peri-implantitis ranged from 19% to 65% [9Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects. J Clin Periodontol 2006; 33(12): 929-35.
[http://dx.doi.org/10.1111/j.1600-051X.2006.01001.x] [PMID: 17092244]
].

Being aware of the histological differences between the peri-implant tissue and the periodontium is fundamental to better understand the peri-implant tissue biology. Natural dentition and osteointegrated dental implants have been compared histologically. Berglundh et al. carried out an animal study on beagle dogs, comparing peri-implant and periodontal tissue histology through block biopsies [10Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, Thomsen P. The soft tissue barrier at implants and teeth. Clin Oral Implants Res 1991; 2(2): 81-90.
[http://dx.doi.org/10.1034/j.1600-0501.1991.020206.x] [PMID: 1809403]
]. Histological examination showed that both oral epithelium and the outward portion of peri-implant mucosa presented well-keratinized areas, but while the first one was followed by sulcular and junctional epithelium (attached to the enamel surface), the second one was not, presenting only a few cells and thick epithelium in contact with the implant abutment. Another important difference was found in collagen arrangement: peri-implant tissue fibers showed a parallel course originating from the crestal bone, while the periodontal fibers course was perpendicular to dental root, going from root cementum to alveolar bone [10Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, Thomsen P. The soft tissue barrier at implants and teeth. Clin Oral Implants Res 1991; 2(2): 81-90.
[http://dx.doi.org/10.1034/j.1600-0501.1991.020206.x] [PMID: 1809403]
]. Also, the blood supply is anatomically different between the peri-implant tissues and the periodontium: peri-implant bone vessels only consist of the periosteum source, while the gingiva supply is guaranteed by a double source, composed by supra-periosteal and periodontal ligament vessels [11Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the vascular systems in the periodontal and peri-implant tissues in the dog. J Clin Periodontol 1994; 21(3): 189-93.
[http://dx.doi.org/10.1111/j.1600-051X.1994.tb00302.x] [PMID: 8157772]
].

Clinicians, implant rehabilitated patients and dental industry have based on their maintenance approaches on techniques and tools derived from a pre-implant era. Also, all the knowledge of peri-implant home care practices has been based on periodontal ones [12Louropoulou A, Slot DE, Van der Weijden F. Mechanical self-performed oral hygiene of implant supported restorations: A systematic review J Evid Based Dent Pract 2014; 14 Suppl:60-9,e1.].

As already stated [9Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects. J Clin Periodontol 2006; 33(12): 929-35.
[http://dx.doi.org/10.1111/j.1600-051X.2006.01001.x] [PMID: 17092244]
], the correlation between plaque accumulation and inflammatory lesions in osteointegrated implants have been shown and this is the reason to focus on plaque control, despite good oral hygiene it is difficult due to prosthetic rehabilitation [13Vandekerckhove B, Quirynen M, Warren PR, Strate J, van Steenberghe D. The safety and efficacy of a powered toothbrush on soft tissues in patients with implant-supported fixed prostheses. Clin Oral Investig 2004; 8(4): 206-10.
[http://dx.doi.org/10.1007/s00784-004-0278-z] [PMID: 15583919]
].

Several tools are commonly used to prevent plaque accumulation in patients with dental implants rehabilitations: manual and powered toothbrushes, mouth rinses and interproximal aids, such as dental floss and proxa-brushes.

Patients have to be instructed regarding proper use during oral hygiene motivation according to the type of rehabilitation and patient skills. For example, a powered toothbrush can facilitate oral hygiene practice in elderly people or in not manual skilled ones [14Tawse-Smith A, Duncan WJ, Payne AG, Thomson WM, Wennström JL. Relative effectiveness of powered and manual toothbrushes in elderly patients with implant-supported mandibular overdentures. J Clin Periodontol 2002; 29(4): 275-80.
[http://dx.doi.org/10.1034/j.1600-051X.2002.290401.x] [PMID: 11966923]
]. Toothbrushes, however, are not enough for good cleansing, since interproximal spaces are not reached during the cleaning practice, and this leads to a higher risk of inflammation. There are a lot of interproximal cleaning devices available in the market, and even though they are effective, patients rarely use them constantly, because they are difficult and time-consuming [15Chongcharoen N, Lulic M, Lang NP. Effectiveness of different interdental brushes on cleaning the interproximal surfaces of teeth and implants: A randomized controlled, double-blind cross-over study. Clin Oral Implants Res 2012; 23(5): 635-40.
[http://dx.doi.org/10.1111/j.1600-0501.2011.02387.x] [PMID: 22146002]
].

Peri-implant and periodontal tissues have also similarities in microbial colonization: in both, there is a proportional growth for the bacterial frequency from a healthy to an unhealthy status, with analog presences of Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Treponema denticola, Fusobacterium nucleatum, Prevotella intermedia and Staphylococcus aureus [16Zhuang LF, Watt RM, Mattheos N, Si MS, Lai HC, Lang NP. Periodontal and peri-implant microbiota in patients with healthy and inflamed periodontal and peri-implant tissues. Clin Oral Implants Res 2016; 27(1): 13-21.
[http://dx.doi.org/10.1111/clr.12508] [PMID: 25399962]
]. Since these bacterial features, it is reasonable to take into account a chemotherapeutic approach with substances that show an antimicrobial effect (chlorhexidine) to inhibit biofilm formation around dental implants [17Miller SA, Forrest JL. Enhancing your practice through evidence-based decision making: PICO, learning how to ask good questions. J Evid Based Dent Pract 2001; 1(2): 136-41.
[http://dx.doi.org/10.1016/S1532-3382(01)70024-3]
].

The aim of this review is to identify the presence of scientific evidence that peri-implant home care is effective in mucositis and peri-implantitis prevention.

2. MATERIALS AND METHODS

The focused question for literature search Is there a scientific evidence reported in the literature that we are using the proper hygiene tools or antimicrobials for dental implants rehabilitation homecare to prevent mucositis and peri-implantitis?” was structured according to the PICO format [18Wolff L, Kim A, Nunn M, Bakdash B, Hinrichs J. Effectiveness of a sonic toothbrush in maintenance of dental implants. A prospective study. J Clin Periodontol 1998; 25(10): 821-8.
[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02376.x] [PMID: 9797055]
].

  • Population: Patients rehabilitated with dental implants.
  • Intervention: Homecare cleaning practice of implant, implant prosthesis and peri-implant tissue.
  • Comparison: Different homecare practices.
  • Outcome: Finding if there is any evidence and which is the best homecare strategy for mucositis/periimplantitis prevention.

PubMed, Embase, MEDLINE, Web of Science and Cochrane databases were used in order to detect publications reflecting the inclusion criteria. The search looked into peri-implant homecare studies published from 1991 to 2019. The terms used for the identification of keywords were: Dental implants, Brush, Interproximal brushing, Interdental brushing, Power toothbrush, Cleaning, Interdental cleaning, Interspace cleaning, Flossing, Super floss, Mouth rinses, Chlorhexidine.

The inclusion criteria used for screening were papers written in the English language, with available abstract, conducted in humans having at least one dental implant, reporting on homecare dental implant practices.

The exclusion criteria were: papers in a language other than English, works with abstract that was not available, non clinical studies, absence of dental implants, studies not reporting on homecare implant practices.

The type of studies included in the selection for this structured review was Randomized Clinical Trials (RCTs), Controlled Clinical Trials (CCTs), Systematic Reviews, Reviews, Consensus papers, Cohort Studies and Clinical cases.

Studies were first screened by titles and abstracts and examined by two reviewers (F.R. and L.L.B.); studies that fulfilled the inclusion criteria were selected, the full text of the selected papers was found and data was analyzed.

Full text studies admitted for final selection were divided into two groups: high and low evidence groups.

The studies that fulfilled the following criteria where classified as high evidence: RCT and COHORT studies with 6 months follow up, 20 patients, analyzing Probing Pocket Depth (PPD), Plaque Index (PI) or Bleeding Index (BI) or Bleeding on Probing (BoP); Consensus papers; systematic reviews/ reviews and case control studies that analyze Plaque Index (PI) and Probing Pocket Depth (PPD).

3. RESULTS

Seven studies fulfilled all the inclusion criteria, respectively three RCTs [19Truhlar RS, Morris HF, Ochi S. The efficacy of a counter-rotational powered toothbrush in the maintenance of endosseous dental implants. J Am Dent Assoc 2000; 131(1): 101-7.
[http://dx.doi.org/10.14219/jada.archive.2000.0028] [PMID: 10649881]
-21Renvert S, Hirooka H, Polyzois I, Kelekis-Cholakis A, Wang HL. Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants - Consensus report of working group 3. Int Dent J 2019; 69(Suppl. 2): 12-7.
[http://dx.doi.org/10.1111/idj.12490] [PMID: 31478575]
], one Consensus report [22Vandekerckhove B, Quirynen M, Warren PR, Strate J, van Steenberghe D. The safety and efficacy of a powered toothbrush on soft tissues in patients with implant-supported fixed prostheses. Clin Oral Investig 2004; 8(4): 206-10.
[http://dx.doi.org/10.1007/s00784-004-0278-z] [PMID: 15583919]
], one cohort study [23Louropoulou A, Slot DE, Van der Weijden F. Mechanical self-performed oral hygiene of implant supported restorations: A systematic review. J Evid Based Dent Pract 2014; 14(Suppl.): 60-9.e1.
[http://dx.doi.org/10.1016/j.jebdp.2014.03.008] [PMID: 24929590]
], one systematic review [24Grusovin MG, Coulthard P, Worthington HV, George P, Esposito M. Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants. Cochrane Database Syst Rev 2010; (8): CD003069
[http://dx.doi.org/10.1002/14651858.CD003069.pub4] [PMID: 20687072]
] and one Chochrane review [25The periodic health examination. Can Med Assoc J 1979; 121(9): 1193-254.
[PMID: 115569]
].

The seven selected studies were grouped according to their keyword and referring Mesh in Table. 1.

Among these, one single blind parallel arm RCT study compared manual versus sonic toothbrush, concluding that there was a significant reduction for both toothbrushes (p<0.005) in BI, PI, GI, PPD [19Truhlar RS, Morris HF, Ochi S. The efficacy of a counter-rotational powered toothbrush in the maintenance of endosseous dental implants. J Am Dent Assoc 2000; 131(1): 101-7.
[http://dx.doi.org/10.14219/jada.archive.2000.0028] [PMID: 10649881]
]. One cohort study on 100 patients revealed that there was the absence of tissue desquamation and/or ulceration, a significant reduction of PPD (p<0.001) and REC (p<0.001) using a powered toothbrush [23Louropoulou A, Slot DE, Van der Weijden F. Mechanical self-performed oral hygiene of implant supported restorations: A systematic review. J Evid Based Dent Pract 2014; 14(Suppl.): 60-9.e1.
[http://dx.doi.org/10.1016/j.jebdp.2014.03.008] [PMID: 24929590]
]. One multicenter CCT analyzed the effect of powered toothbrushes on 2966 implant-supported restorations, showing that this device has a statistically significant higher plaque removal effect than the manual method (p<0.001) [20Swierkot K, Brusius M, Leismann D, et al. Manual versus sonic-powered toothbrushing for plaque reduction in patients with dental implants: An explanatory randomised controlled trial. Eur J Oral Implantology 2013; 6(2): 133-44.
[PMID: 23926585]
]. A single blind RCT conduct on 83 patients and 290 implants instead reported no statistically significant differences between groups in BOP, GI, PPD and PI [21Renvert S, Hirooka H, Polyzois I, Kelekis-Cholakis A, Wang HL. Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants - Consensus report of working group 3. Int Dent J 2019; 69(Suppl. 2): 12-7.
[http://dx.doi.org/10.1111/idj.12490] [PMID: 31478575]
]. Also, Grusovin et al. found no statistically significant differences between manual and powered toothbrushes [25The periodic health examination. Can Med Assoc J 1979; 121(9): 1193-254.
[PMID: 115569]
]. A consensus report in 2019 concerning homecare maintenance stated that manual and powered toothbrushes are both equally useful in peri-implant health maintenance and that interdental brushes and dental floss are effective differently from the use of antiseptic mouthwashes [22Vandekerckhove B, Quirynen M, Warren PR, Strate J, van Steenberghe D. The safety and efficacy of a powered toothbrush on soft tissues in patients with implant-supported fixed prostheses. Clin Oral Investig 2004; 8(4): 206-10.
[http://dx.doi.org/10.1007/s00784-004-0278-z] [PMID: 15583919]
]. Louropoulou et al. ended their systematic review concluding that there was still a lack of evidence for the best homecare maintenance practice [24Grusovin MG, Coulthard P, Worthington HV, George P, Esposito M. Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants. Cochrane Database Syst Rev 2010; (8): CD003069
[http://dx.doi.org/10.1002/14651858.CD003069.pub4] [PMID: 20687072]
].

The 14 studies that partially met the inclusion criteria (Table. 2) were analyzed and classified into 3 different levels of evidence: good evidence for RCTs, fair evidence for case control and cohort studies and poor evidence for expert opinion and case report [26Heitz-Mayfield LJ, Salvi GE, Botticelli D, Mombelli A, Faddy M, Lang NP. Anti-infective treatment of peri-implant mucositis: A randomised controlled clinical trial. Clin Oral Implants Res 2011; 22(3): 237-41.
[http://dx.doi.org/10.1111/j.1600-0501.2010.02078.x] [PMID: 21251076]
].

Six articles analyzed the peri-implant maintenance describing the efficacy of Chlorhexidine (CHX) [27Genovesi A, Barone A, Toti P, Covani U. The efficacy of 0.12% chlorhexidine versus 0.12% chlorhexidine plus hyaluronic acid mouthwash on healing of submerged single implant insertion areas: A short-term randomized controlled clinical trial. Int J Dent Hyg 2017; 15(1): 65-72.
[http://dx.doi.org/10.1111/idh.12158] [PMID: 26084554]
-32Ciancio SG, Lauciello F, Shibly O, Vitello M, Mather M. The effect of an antiseptic mouthrinse on implant maintenance: Plaque and peri-implant gingival tissues. J Periodontol 1995; 66(11): 962-5.
[http://dx.doi.org/10.1902/jop.1995.66.11.962] [PMID: 8558397]
]. CHX gel seemed to decrease BI, BoP, PI and PPD values [27Genovesi A, Barone A, Toti P, Covani U. The efficacy of 0.12% chlorhexidine versus 0.12% chlorhexidine plus hyaluronic acid mouthwash on healing of submerged single implant insertion areas: A short-term randomized controlled clinical trial. Int J Dent Hyg 2017; 15(1): 65-72.
[http://dx.doi.org/10.1111/idh.12158] [PMID: 26084554]
, 29Felo A, Shibly O, Ciancio SG, Lauciello FR, Ho A. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent 1997; 10(2): 107-10.
[PMID: 9545899]
-32Ciancio SG, Lauciello F, Shibly O, Vitello M, Mather M. The effect of an antiseptic mouthrinse on implant maintenance: Plaque and peri-implant gingival tissues. J Periodontol 1995; 66(11): 962-5.
[http://dx.doi.org/10.1902/jop.1995.66.11.962] [PMID: 8558397]
], and showed ability in reducing edema in anti-phlogistic activity [28Keltjens HM, Schaeken MJ, van der Hoeven JS, Hendriks JC. Effects of chlorhexidine gel on periodontal health of abutment teeth in patients with overdentures. Clin Oral Implants Res 1991; 2(2): 71-4.
[http://dx.doi.org/10.1034/j.1600-0501.1991.020204.x] [PMID: 1809401]
]. Other mouth rinse agents seemed to be effective in reducing Bi and GI [33Pedrazzi V, Escobar EC, Cortelli JR, et al. Antimicrobial mouthrinse use as an adjunct method in peri-implant biofilm control. Braz Oral Res 2014; 28(Spec No): S1806-83242014000200301.
[http://dx.doi.org/10.1590/1807-3107BOR-2014.vol28.0022] [PMID: 25003787]
] and in inhibiting biofilm formation [34Rasperini G, Pellegrini G, Cortella A, Rocchietta I, Consonni D, Simion M. The safety and acceptability of an electric toothbrush on peri-implant mucosa in patients with oral implants in aesthetic areas: A prospective cohort study. Eur J Oral Implantology 2008; 1(3): 221-8.
[PMID: 20467624]
].

One cohort study with 100 patients and 12 months of follow up showed that powered toothbrushes are able to significantly reduce PPD, REC and bleeding score, more than manual toothbrushes [35Chongcharoen N, Lulic M, Lang NP. Effectiveness of different interdental brushes on cleaning the interproximal surfaces of teeth and implants: A randomized controlled, double-blind cross-over study. Clin Oral Implants Res 2012; 23(5): 635-40.
[http://dx.doi.org/10.1111/j.1600-0501.2011.02387.x] [PMID: 22146002]
]. A single blind RCT performed on 40 patients instead concluded that there was no statistically significant PI and BI reduction, nor any differences between brushing methods [15Chongcharoen N, Lulic M, Lang NP. Effectiveness of different interdental brushes on cleaning the interproximal surfaces of teeth and implants: A randomized controlled, double-blind cross-over study. Clin Oral Implants Res 2012; 23(5): 635-40.
[http://dx.doi.org/10.1111/j.1600-0501.2011.02387.x] [PMID: 22146002]
].

Interdental devices have been suggested for implant-supported prosthesis homecare since they are able to reduce PI and BoP [36Magnuson B, Harsono M, Stark PC, Lyle D, Kugel G, Perry R. Comparison of the effect of two interdental cleaning devices around implants on the reduction of bleeding: A 30-day randomized clinical trial. Compend Contin Educ Dent 2013; 34(Spec No 8): 2-7.
[PMID: 24568169]
, 37van Velzen FJ, Lang NP, Schulten EA, Ten Bruggenkate CM. Dental floss as a possible risk for the development of peri-implant disease: An observational study of 10 cases. Clin Oral Implants Res 2016; 27(5): 618-21.
[http://dx.doi.org/10.1111/clr.12650] [PMID: 26261052]
], whereas superfloss could be a risk factor for peri-implantitis development in case of implant threads exposure [38Grusovin MG, Coulthard P, Worthington HV, Esposito M. Maintaining and recovering soft tissue health around dental implants: A Cochrane systematic review of randomised controlled clinical trials. Eur J Oral Implantology 2008; 1(1): 11-22.
[PMID: 20467640]
].

In a systematic review by the Chochrane group of Grusovin et al., 9 studies were included in order to identify the best practice for peri-implant homecare. The authors concluded that there was little evidence of what the best practices were [39Mombelli A. Maintenance therapy for teeth and implants. Periodontol 2000 2019; 79(1): 190-9.
[http://dx.doi.org/10.1111/prd.12255] [PMID: 30892766]
].

4. DISCUSSION

In a recent review, Mombelli stated that preventive homecare measures taken by the patient are the first component of maintenance after dental implant therapy. These include personal oral hygiene, avoidance of environmental risks (such as tobacco smoke) and management of systemic diseases (such as diabetes) [40Salvi GE, Ramseier CA. Efficacy of patient-administered mechanical and/or chemical plaque control protocols in the management of peri-implant mucositis. A systematic review. J Clin Periodontol 2015; 42(16)(Suppl. 16): S187-201.
[http://dx.doi.org/10.1111/jcpe.12321] [PMID: 25495416]
].

Table 1
High evidence studies grouped according to referring Mesh.


Table 2
Low evidence studies which partially met the inclusion criteria.


Since the presence of biofilm around implant-supported prosthesis has been proven to develop inflammation and peri-implant disease, the aim of professional maintenance and homecare should be pointed towards biofilm elimination. Oral hygiene instructions have to be delivered appropriately, and the patient must understand the importance of adequate hygiene around implants [41Bidra AS, Daubert DM, Garcia LT, et al. Clinical practice guidelines for recall and maintenance of patients with tooth-borne and implant-borne dental restorations. J Prosthodont 2016; 25(1)(Suppl. 1): S32-40.
[http://dx.doi.org/10.1111/jopr.12416] [PMID: 26711219]
, 42Izadi M, Moghareabed A, Nasiri S, Tavakoli M, Yaghini J. Maintenance of dental implants: A review. J Dent Sch 2013; 31(4): 242-52.].

Patients receiving implant treatment usually have a history of poor homecare resulting in partial or complete teeth loss [43Quirynen M, van der Mei HC, Bollen CM, et al. An in vivo study of the influence of the surface roughness of implants on the microbiology of supra- and subgingival plaque. J Dent Res 1993; 72(9): 1304-9.
[http://dx.doi.org/10.1177/00220345930720090801] [PMID: 8395545]
] and high plaque index has a positive correlation with peri-implant mucositis and an increase of PPD [44Montevecchi M, De Blasi V, Checchi L. Is implant flossing a risk-free procedure? A case report with a 6-year follow-up. Int J Oral Maxillofac Implants 2016; 31(3): e79-83.
[http://dx.doi.org/10.11607/jomi.4263] [PMID: 27183086]
].

Various studies showed that powered toothbrushes have clinical effectiveness in dental implant maintenance, but because of differences in study designs, results should be interpreted with caution.

Wolff et al, in 1998 compared sonic versus manual toothbrushes for plaque index and gingivitis around implants [19Truhlar RS, Morris HF, Ochi S. The efficacy of a counter-rotational powered toothbrush in the maintenance of endosseous dental implants. J Am Dent Assoc 2000; 131(1): 101-7.
[http://dx.doi.org/10.14219/jada.archive.2000.0028] [PMID: 10649881]
]. In this single blind parallel arm RCT, patients were randomly selected and instructed to the use of a powered sonic toothbrush or a manual one. The duration of this study was six months and the 31 patients after baseline were recalled at 4, 8, 12 and 24 weeks to evaluate PPD, GI, BI, PI. Both techniques showed a statistically significant reduction of PI, BI and GI (p<0.005) and the group using the sonic device showed at every control a constantly lower, but not statistically significant, probing depth values. According to these results and to the high level of compliance, the sonic toothbrush seems to be a very effective tool for the implant homecare maintenance.

Vandekerckhove et al., in a prospective cohort study analyzed the efficacy of oscillating/rotating powered toothbrush on a 100 patient recording probing depth, BI, SBI and recession at baseline and at 12, 24, and 52 weeks [23Louropoulou A, Slot DE, Van der Weijden F. Mechanical self-performed oral hygiene of implant supported restorations: A systematic review. J Evid Based Dent Pract 2014; 14(Suppl.): 60-9.e1.
[http://dx.doi.org/10.1016/j.jebdp.2014.03.008] [PMID: 24929590]
].

Also, Truhlar et al., in a multicenter CCT compared powered counter rotational and manual toothbrush efficacy, measuring PI, GI, PPD and recession. The authors concluded that there was a statistically significant reduction of PI in the 24 months follow up (P<0,001) for the patients' group that used the powered device [20Swierkot K, Brusius M, Leismann D, et al. Manual versus sonic-powered toothbrushing for plaque reduction in patients with dental implants: An explanatory randomised controlled trial. Eur J Oral Implantology 2013; 6(2): 133-44.
[PMID: 23926585]
].

These data seem to underline the importance of a powered toothbrush in implant-supported rehabilitations homecare but two recent RCTs compared oscillating/rotating and sonic toothbrushes with the traditional manual technique and in both studies, no statistically significant differences in peri-implant inflammatory parameters were noticed [14Tawse-Smith A, Duncan WJ, Payne AG, Thomson WM, Wennström JL. Relative effectiveness of powered and manual toothbrushes in elderly patients with implant-supported mandibular overdentures. J Clin Periodontol 2002; 29(4): 275-80.
[http://dx.doi.org/10.1034/j.1600-051X.2002.290401.x] [PMID: 11966923]
, 21Renvert S, Hirooka H, Polyzois I, Kelekis-Cholakis A, Wang HL. Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants - Consensus report of working group 3. Int Dent J 2019; 69(Suppl. 2): 12-7.
[http://dx.doi.org/10.1111/idj.12490] [PMID: 31478575]
].

Study design, study length and kinds of implant restorations differed significantly among all these studies and this is probably the reason why it is so difficult to make a direct comparison. Both manual and powered toothbrushes are effective in peri-implant soft tissue health maintenance, with no reports of adverse effects on soft tissues reported for powered toothbrushes. Today there is no clear evidence that powered toothbrushes are better than manual devices in gaining peri-implant health. Therefore, it is very important that the dental clinician is able to give detailed and personalized oral hygiene instructions based on single patient ability.

Only a few studies focused on interproximal devices and interdental plaque control.

Chongcharoen et al. in a cross-over 2 weeks follow up single-blind RCT, examined plaque removal efficacy of two interdental brushes both at tooth and implant sites through the comparison of two devices with different shapes [36Magnuson B, Harsono M, Stark PC, Lyle D, Kugel G, Perry R. Comparison of the effect of two interdental cleaning devices around implants on the reduction of bleeding: A 30-day randomized clinical trial. Compend Contin Educ Dent 2013; 34(Spec No 8): 2-7.
[PMID: 24568169]
]. Patients were randomly assigned to the different interdental brushes groups, and PI values were recorded. Results showed that plaque reduction was significantly high for both tools (P< 0,0001), demonstrating that interdental brushes are effective tools for dental implant homecare maintenance.

Water floss was analyzed in one RCT in which water flossing and flossing around implants were analyzed through the reduction of BoP in one month follow up [37van Velzen FJ, Lang NP, Schulten EA, Ten Bruggenkate CM. Dental floss as a possible risk for the development of peri-implant disease: An observational study of 10 cases. Clin Oral Implants Res 2016; 27(5): 618-21.
[http://dx.doi.org/10.1111/clr.12650] [PMID: 26261052]
]. After 30 days, 81.8% of implants in the water flosser group showed a reduction in BOP compared to 33.3% in the floss group (P=0.0018), suggesting the water-floss could be useful in dental implant homecare maintenance. An important bias of this study could be the fact that interdental oral hygiene was carried out by a dental assistant and not directly by the patient.

Some attention should be paid to two observational studies [38Grusovin MG, Coulthard P, Worthington HV, Esposito M. Maintaining and recovering soft tissue health around dental implants: A Cochrane systematic review of randomised controlled clinical trials. Eur J Oral Implantology 2008; 1(1): 11-22.
[PMID: 20467640]
, 45Edwin XJ. Goh | Lum Peng Lim Implant maintenance for the prevention of biological complications: Are you ready for the next challenge? 2016; 1-9.] regarding the alarming correlation between developing peri-implant disease and flossing. Montevecchi et al. described a case report of a 66 old man with two complete dentures on implants [45Edwin XJ. Goh | Lum Peng Lim Implant maintenance for the prevention of biological complications: Are you ready for the next challenge? 2016; 1-9.]. The patient showed pathological probing values, pain, edema and other signs of inflammation even after the application of CHX gel. During the following visit, an endoscopy examination revealed a large amount of filamentous foreign body around each implant. An extra-oral analysis of this residual concluded that it was part of the super-floss used by the patient during homecare practices. Ten days after the removal of the foreign body, a complete remission was observed.

Van Velzen et al. came to similar findings in their observational study: ten patients with progressive peri-implantitis and not responding to therapies were selected for exploratory surgery, assessing PI, BI and PPD before and after the surgical interventions [38Grusovin MG, Coulthard P, Worthington HV, Esposito M. Maintaining and recovering soft tissue health around dental implants: A Cochrane systematic review of randomised controlled clinical trials. Eur J Oral Implantology 2008; 1(1): 11-22.
[PMID: 20467640]
]. After raising a mucoperiosteal flap, bone defect was cleaned and filled with autologous bone. In all patients, remnants of floss were found and eliminated.

Remnants of floss occurred in those implants with fixture exposure or rough surfaces; in these clinical conditions, the use of interdental brushes could be suggested instead, recommending the largest size that can fit the interdental space.

However, this recommendation is based on a report of ten patients only. All of these patients were under progressive peri-implantitis and exposed rough implant surface; therefore these results should not be generalized.

As underlined in a systematic review by Louropoulou et al., there is a paucity of studies analyzing the efficacy of interdental tools. Most of the available knowledge about their plaque removal efficacy is based on natural dentition rather than on implants [12Louropoulou A, Slot DE, Van der Weijden F. Mechanical self-performed oral hygiene of implant supported restorations: A systematic review J Evid Based Dent Pract 2014; 14 Suppl:60-9,e1.-45Edwin XJ. Goh | Lum Peng Lim Implant maintenance for the prevention of biological complications: Are you ready for the next challenge? 2016; 1-9.]. To date, there is very little scientific evidence on the efficacy of interdental biofilm removal by the patient in dental implant homecare.

Concerning antimicrobials, a variety of products have been tested and reported as chemotherapeutic agents for plaque control.

The use of chlorhexidine, mouthwash or gel, is considered as an effective antimicrobial device for dental implant maintenance.

Among them, it is very interesting a single blind parallel arm RCT study in which subgingival irrigation (0,06%) and mouthwash (0,12%) with chlorhexidine were compared [30Hallström H, Lindgren S, Twetman S. Effect of a chlorhexidine-containing brush-on gel on peri-implant mucositis. Int J Dent Hyg 2017; 15(2): 149-53.
[http://dx.doi.org/10.1111/idh.12184] [PMID: 26467301]
]. Twenty-four patients having at least two dental implants and prosthodontically restored with complete dentures were followed for 3 months and randomly divided into two groups, one using the chlorhexidine mouthwash (0,12%) and the other using the subgingival irrigation, having their PPD, PI, GI, BI, MGI, CI, SI and calculus index evaluated at baseline and at the end of the follow up. Since there was statistical significant reduction of the MGI, PI, BI and CI scores, subgingival chlorhexidine (0,06%) irrigation seemed to be an effective tool for dental homecare maintenance.

Two different RCT compared the use of chlorhexidine gels to either mouthwash or placebo. They both reported no statistically significant differences between test and control groups [27Genovesi A, Barone A, Toti P, Covani U. The efficacy of 0.12% chlorhexidine versus 0.12% chlorhexidine plus hyaluronic acid mouthwash on healing of submerged single implant insertion areas: A short-term randomized controlled clinical trial. Int J Dent Hyg 2017; 15(1): 65-72.
[http://dx.doi.org/10.1111/idh.12158] [PMID: 26084554]
, 32Ciancio SG, Lauciello F, Shibly O, Vitello M, Mather M. The effect of an antiseptic mouthrinse on implant maintenance: Plaque and peri-implant gingival tissues. J Periodontol 1995; 66(11): 962-5.
[http://dx.doi.org/10.1902/jop.1995.66.11.962] [PMID: 8558397]
].

In a study by Pedrazzi et al., no differences have been found in plaque score and PPD in patients rehabilitated with fixed implant prosthesis, between hyaluronic acid and chlorhexidine gel (0,2%) application after 6 months of follow up [34Rasperini G, Pellegrini G, Cortella A, Rocchietta I, Consonni D, Simion M. The safety and acceptability of an electric toothbrush on peri-implant mucosa in patients with oral implants in aesthetic areas: A prospective cohort study. Eur J Oral Implantology 2008; 1(3): 221-8.
[PMID: 20467624]
]. Instead, a statistically significant difference was found by other authors in the reduction of PI, BI and GI around implants after 3 months of use of Listerine mouthwash [33Pedrazzi V, Escobar EC, Cortelli JR, et al. Antimicrobial mouthrinse use as an adjunct method in peri-implant biofilm control. Braz Oral Res 2014; 28(Spec No): S1806-83242014000200301.
[http://dx.doi.org/10.1590/1807-3107BOR-2014.vol28.0022] [PMID: 25003787]
]. Ciancio et al. analyzed the efficacy of Listerine mouthwash in reducing PI, BI and GI around implant, finding statistical significant decrease (P<0,01) of the indexes [33Pedrazzi V, Escobar EC, Cortelli JR, et al. Antimicrobial mouthrinse use as an adjunct method in peri-implant biofilm control. Braz Oral Res 2014; 28(Spec No): S1806-83242014000200301.
[http://dx.doi.org/10.1590/1807-3107BOR-2014.vol28.0022] [PMID: 25003787]
].

In this review every reported paper taking into account chlorhexidine effect shows a statistically significant decrease of PI and BI [29Felo A, Shibly O, Ciancio SG, Lauciello FR, Ho A. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent 1997; 10(2): 107-10.
[PMID: 9545899]
, 30Hallström H, Lindgren S, Twetman S. Effect of a chlorhexidine-containing brush-on gel on peri-implant mucositis. Int J Dent Hyg 2017; 15(2): 149-53.
[http://dx.doi.org/10.1111/idh.12184] [PMID: 26467301]
], however, none of them meet the high evidence inclusion criteria. Moreover, many study designs include also the mechanical removal of plaque, thus masking the real antimicrobial effect. Selected studies showed that chlorhexidine, in different concentrations, has high antimicrobial effect, but it has not been demonstrated to be beneficial on clinical parameters. In conclusion, it could be considered an effective tool for dental implant homecare practices to prevent peri-implantitis [27Genovesi A, Barone A, Toti P, Covani U. The efficacy of 0.12% chlorhexidine versus 0.12% chlorhexidine plus hyaluronic acid mouthwash on healing of submerged single implant insertion areas: A short-term randomized controlled clinical trial. Int J Dent Hyg 2017; 15(1): 65-72.
[http://dx.doi.org/10.1111/idh.12158] [PMID: 26084554]
-32Ciancio SG, Lauciello F, Shibly O, Vitello M, Mather M. The effect of an antiseptic mouthrinse on implant maintenance: Plaque and peri-implant gingival tissues. J Periodontol 1995; 66(11): 962-5.
[http://dx.doi.org/10.1902/jop.1995.66.11.962] [PMID: 8558397]
].

CONCLUSION

A lot of research has been carried out regarding implant dentistry, peri-implant mucositis and peri-implantitis professional treatment, however according to the above data, little has been done regarding homecare implant maintenance. Based on this review, scientific literature seems to show little evidence in homecare implant maintenance practices, as compared to professional implant care and surgery, so that at present most of the current knowledge in homecare implant practices and tools are taken from periodontal literature.

Both manual and powered toothbrushes, dental floss and interdental brushes seem to be useful in maintaining peri-implant health. Caution is recommended on the use of dental floss when rough implant surfaces are exposed.

The use of antiseptic rinses or gels does not seem to have any beneficial effects.

The dental practitioner has the most important role to personalize oral hygiene instructions based on patient abilities.

It can be concluded that to better understand which are the most effective homecare practices to prevent mucositis and peri-implantitis in implant-rehabilitated patients, new specific high evidence studies are needed.

CONSENT FOR PUBLICATION

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors are extremely grateful to Dr. Maria Rosaria Gatto, DIBINEM, University of Bologna, for her contribution to the statistical analyses.

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