Received: 31 March 2020 | Revised: 3 July 2020 | Accepted: 27 July 2020

DOI: 10.1111/jcpe.13357

ORIGINAL ARTICLE CLINICAL PERIODONTOLOGY

Supportive treatment following peri-implantitis surgery:

An RCT using titanium curettes or chitosan brushes

Odd Carsten Koldsland | Anne Merete Aass

Department of Periodontology, Institute

of Clinical Dentistry, Faculty of Dentistry, Abstract
University of Oslo, Oslo, Norway Aims: The aim of this randomized controlled trial was to assess the effect of two
Correspondence maintenance programmes when treatments were performed every third month from
Odd Carsten Koldsland, Department of six to 18 months following surgical treatment of peri-implantitis.
Periodontology, Faculty of Dentistry,
Institute of Clinical Dentistry, University of Materials and methods: At the 6-month post-surgical evaluation, 44 subjects were
Oslo, Oslo, Norway. randomized into groups receiving supportive peri-implant treatment either by the
Email: [email protected]
use of titanium curettes or chitosan brushes at implants registered with BoP and PPD
Funding information >3 mm. Follow-up examinations and supportive therapy were performed 6, 9, 12,
The Faculty of Dentistry, University of Oslo,
Norway supported the study. 15 and 18 months post-surgically. Clinical and radiographic assessments were made.
Results: The percentage of implants registered with inflammation was high at the
6-month baseline examination (>80% bleeding on probing in both test and control
group) and remained high throughout the observation period. Similar observations
were made for all clinical parameters, and no significant difference was found be-
tween test and control groups.
Conclusions: In the present study, no statistical significant difference was found when
supportive peri-implant treatment was performed with either titanium curettes or chi-
tosan brushes. Within the limits of the study, the results might indicate the need of
more effective submucosal cleaning procedures following peri-implant surgery.

KEYWORDS

dental/oral implants, peri-implantitis, supportive peri-implant treatment

in the short term (Karlsson et al., 2019; Renvert et al., 2012). Success
1 | I NTRO D U C TI O N might be hard to maintain in the long term though. Maintenance
after implant insertion and functional loading has previously been
The last decades, several reports have stated that peri-implant dis- described as having three components: measures taken by the pa-
eases are relatively common (Derks et al., 2016; Koldsland, Scheie, tient, preventive procedures carried out by dental health profession-
& Aass, 2010; Roos-Jansåker, Lindahl, Renvert, & Renvert, 2006a). als and the supportive peri-implant therapy (SPiT) that intervenes
No specific treatment procedure has been identified as superior for disease (Mombelli, 2019). Hence, the objectives for the dental team
peri-implantitis (Renvert, Polyzois, & Claffey, 2012). Even so, surgical in this situation should be individually tailored oral hygiene instruc-
therapy has been reported as a preferable method for treating peri- tions aiming at optimal home care performed by the patient (Salvi &
implantitis and patients receiving this therapy have benefited from it Ramseier, 2014) and chair-side procedures aiming at prevention of

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2020 The Authors. Journal of Clinical Periodontology published by John Wiley & Sons Ltd

J Clin Periodontol. 2020;47:1259–1267.  wileyonlinelibrary.com/journal/jcpe | 1259

1260 | KOLDSLAND and AASS

disease (removal of supragingival deposits and polishing) or inter-

vention of existing peri-implant disease (SPiT). Disease eradication
Clinical relevance
might be difficult to achieve and maintain even at implants with in-
Scientific rationale for the study: The current paper as-
tact bone support (Heitz-Mayfield et al., 2011; Maximo et al., 2009).
sessed the efficacy of chitosan brushes (test) and titanium
Maintenance after surgical treatment of peri-implantitis is essen-
curettes (control) used in post-surgical supportive peri-
tial and is heavily dependent on prognostic factors at both sub-
implant therapy.
ject and implant levels (Carcuac et al., 2015; Koldsland, Wohlfahrt,
Principal findings: No statistically significant difference was
& Aass, 2018; Serino & Turri, 2011; de Waal, Raghoebar, Meijer,
found between test and control group. Peri-implant dis-
Winkel, & van Winkelhoff, 2016). The effect of SPiT aiming at eradi-
ease rarely improved.
cation of inflammation and disease might thus be difficult to achieve
Practical implications: Inflammation control was not a pre-
in a clinical situation.
dictable end point in the present study. The results might
Treatment of peri-implantitis has been recommended to fol-
indicate the need of more effective submucosal cleaning
low certain stages: systemic phase, non-surgical debridement,
procedures following peri-implant surgery.
surgical therapy and clinical monitoring with SPiT (Heitz-Mayfield,
Needleman, Salvi, & Pjetursson, 2014). As of today, no gold standard
for maintenance therapy exists, even though several methods of bio-
film removal are available (Armitage & Xenoudi, 2016).
Most studies regarding implant maintenance assess the effect methods and assess the efficacy of these methods following peri-im-
of one or more procedures treating peri-implant mucositis. A review plantitis surgery.
paper by Schwarz, Schmucker, and Becker (2015) reported that me- The aim of this randomized controlled trial was therefore to as-
chanical debridement with, for example carbon, titanium or plastic sess the effect of two supportive treatment methods performed
curettes combined with oral hygiene instruction, was effective in the every third month from 6 to 18 months following surgical peri-im-
management of peri-implant mucositis. These studies assess the ef- plantitis treatment.
ficacy of reducing plaque induced inflammation at smooth implant/
abutment/suprastructure surfaces. Following peri-implant bone loss
and resective peri-implant surgery, a rough surface with implant 2 | M ATE R I A L S A N D M E TH O DS
threads will be exposed to the microbiota environment. In these sit-
uations, implant threads and irregularities of the implant surface may 2.1 | Study design
hamper proper biofilm removal. Hence, the results of clinical studies
assessing treatment of peri-implant mucositis at implants with intact This study was designed as a randomized clinical trial assessing the
bone support might not be directly comparable to studies assessing outcome of two methods when performing SPiT in subjects having
SPiT following peri-implantitis surgery. Studies assessing non-surgi- received surgical treatment for peri-implantitis. The study flow chart
cal peri-implantitis therapy might be comparable to studies following is presented in Figure 1. At the 6-month evaluation, the subjects
peri-implant surgery, but the peri-implant lesions might in general be were randomized (pulling note from envelope) into groups receiv-
less inflamed and access to the implant might be easier following sur- ing treatment either by the use of titanium curettes (Langer and
gery, for both the professional and the patient. The use of a chitosan Langer; Rønvig) or chitosan brushes (LBC, BioClean®; LABRIDA AS).
brush has been evaluated in a previous multicentre case series as Follow-up examinations and supportive treatment were performed
part of a non-surgical procedure treating mild peri-implantitis (pocket 6, 9, 12, 15 and 18 months post-surgically. Registrations from the
probing depth (PPD) ≥4 mm, BoP+ and 1–2 mm bone loss). Significant 6-month evaluation were used as baseline. One blinded examiner
reduction in both PPD and inflammation was observed short term (AMA) performed all post-surgical examinations, and one operator
following the treatment (Wohlfahrt et al., 2017). Non-surgical treat- (OCK) performed all post-surgical treatment. Both are calibrated and
ment of peri-implantitis using curettes with or without supplemental board-certified periodontists.
therapy has also been previously evaluated (Karring, Stavropoulos, The study was approved by the Norwegian Regional Ethics
Ellegaard, & Karring, 2005; Maximo et al., 2009). Even though less Committee, REK south-east (2012/2257) and registered at
inflammation was registered after both modalities of treatment, in- ClinicalTrials.gov (NCT03421717).
flammation control was not a predictable endpoint for either treat- The study was funded by the Faculty of Dentistry, University of
ment. Several other treatments such as laser therapy, photodynamic Oslo.
therapy, airflow and ultrasound instruments are also available for
SPiT, but no treatment modality has shown superiority in eradication
of peri-implant disease (Faggion, Listl, Fruhauf, Chang, & Tu, 2014). 2.2 | Study population
Assessments over a longer period of time (5 years) are reported
(L. J. Heitz-Mayfield et al., 2016; Serino, Turri, & Lang, 2015), but The study population has been presented in a previous publication
to the best of our knowledge, no clinical studies compare different (Koldsland et al., 2018). In short, 45 subjects with a diagnosis of
KOLDSLAND and AASS | 1261

FIGURE 1 Consort flowchart

Six month post op examination
(n = 45, 143 implants)

Randomized (n = 44, 142 implants) No need supportive treatment (n = 1, 1 implant)

Allocated to intervention, Allocated to intervention,

test (n = 22, 57 implants) control (n = 22, 85 implants)

Discontinued intervention Discontinued intervention

after 9 month follow up, -Up after 6 month follow up,
(n = 1, 2 implants) (n = 1, 5 implants)

Analysed (n = 21, 55 implants) Analysed (n = 21, 80 implants)

Total study population (n = 42, 135 implants)

Excluded from bone level analysis (11 implants)

TA B L E 1 Subject characteristics in the

Subject Total Test group Control group
test and control groups
characteristics (n = 42) SD (n = 21) SD (n = 21) SD

Mean age 65 8.8 63 10.3 66 7.0

Males/females 19/23 9/12 10/11
Diabetic 3 1 2
Rheumatic disease 2 0 2
Daily smoker 20 10 10
and/or previous 32 17 15
smoker
Tooth lost due to 32 14 18
periodontitis
Attending regular 41 21 20
recalls

progressive peri-implantitis were surgically treated for peri-implan- 3rd month beginning with the 6-month evaluation until 18 months
titis, not using any regenerative material. postop, the following examinations were performed at six sites, if
Two subjects were lost to follow up (both denied further par- accessible, of the implants:
ticipation due to discomfort when probing and when SPiT was per-
formed). Mean age at time of surgery was 65 years (SD 8.8, range • Suppuration: presence or absence after light pressure against
45–86). Subject characteristics are described in Table 1. Implant gingiva/mucosa
characteristics are described in Table 2. • Plaque: presence or absence recognized by running a probe across
the marginal surface of the implant (Mombelli, van Oosten, Jr, &
Lang, 1987)
2.3 | Clinical assessment and post- • PPD: recorded with a pressure-sensitive probe (20 g) (University
surgical treatment of North Carolina probe, Aesculap, Braun, Tuttlingen, Germany)
• BoP: bleeding/no bleeding within 30 s after measurement of PPD
Prior to surgery, four and twelve weeks after surgery, oral hygiene • Gingival bleeding: registered according to the Modified Sulcus
instruction was given (Koldsland et al., 2018). Thereafter, every Bleeding Index (Mombelli et al., 1987)
1262 | KOLDSLAND and AASS

TA B L E 2 Implant characteristics in the

Control
test and control groups
Implant characteristics Total (%) Test group (%) group (%)

Total 135 55 (40.7) 80 (59.3)

Modified surface 117 (86.7) 50 (90.9) 67 (83.8)
Machined surface 18 (13.3) 5 (9.1) 13 (16.3)
Maxilla 99 (73.3) 44 (80.0) 55 (68.8)
Mandibula 36 (26.7) 11 (20.0) 25 (31.3)
In edentulous jaw 98 (72.6) 36 (65.5) 62 (77.5)
Not in edentulous jaw 37 (27.4) 19 (34.5) 18 (22.5)

The highest clinical registration at each implant represented the following control
implant in the analyses. The implant was regarded positive for BoP/ • Improvement—the implant was registered with peri-implant dis-
suppuration if any site at the implant was registered accordingly. ease at the previous control, SPiT was performed according to
All clinical assessments reported were performed with the su- test or control group procedures. Treatment success was regis-
prastructure in place. tered at the following control
No local anaesthetics were applied or injected prior to the clini- • Persisting disease—the implant was registered with peri-implant
cal measurements. disease, SPiT was performed according to test or control group
procedures
• Impairment—the implant was registered with treatment success at
2.4 | DEFINITIONS the previous control, received basic maintenance treatment. Peri-
implant disease was registered at the following control.
• Implant withdrawn from study: Overt bone loss and/or implants
causing discomfort to the patient. Decision made chair side after The clinical outcomes as defined did not consider radiographic
consensus made by the investigators bone level.
• Peri-implant disease: PPD > 3 mm and BoP/suppuration
• Treatment success: Eradication of peri-implant disease as defined
2.7 | Radiographic examination

2.5 | Treatment procedures Radiographic examination: one examiner (OCK) measured mesial
and distal bone level at 6 and 18 month postop twice (>2 weeks
Basic maintenance treatment: Oral hygiene instruction and peri- between each measurement). The measurements were performed
implant maintenance using rubber cups and pumice. using the software Sectra PACS (IDS7) (Sectra AB, Linköping,
SPiT: Basic maintenance treatment. In addition, subjects with im- Sweden). Implant length and known dimensions of implant threads
plants registered with peri-implant disease, according to the applied were used as reference for calibration of measurements. ICC calcu-
definition, were randomly allocated to control or test group. lated using SPSS (IBM, SPSS statistics, version 24) was 0.98. If the
difference between 1st and 2nd measurement was less than 1.0 mm,
• Control group: SPiT performed with titanium curettes (Langer and the average measurement was used for further analysis. If the differ-
Langer, Rønvig, Denmark) ence between 1st and 2nd measurement was ≥1.0 mm, a consensus
• Test group: SPiT performed using chitosan brushes (LBC, BioClean®, was made (OCK and AMA) to determine the bone level chosen to
LABRIDA AS, Oslo, Norway) seated in an oscillating dental drill represent the implant.
piece (ER10M, TEQ-Y, NSK Inc., Kanuma Tochigi, Japan)

2.8 | Statistics
2.6 | Clinical outcomes
Sample size calculation was based on the results from previous
Four different clinical outcomes were reported at the four time studies assessing the effect of chitosan brushes and titanium cu-
points (9-, 12-, 15- and 18-month controls) following peri-implant rettes in treatment of peri-implant mucositis/mild peri-implanti-
maintenance/SPiT: tis (Renvert, Samuelsson, Lindahl, & Persson, 2009; Wohlfahrt
et al., 2017). To detect a 30% difference in BoP/suppuration be-
• Health stability—the implant was registered with treatment suc- tween test and control, it was calculated that a total of 36 patients
cess at the previous control, received basic maintenance treat- were required to have an 80% chance of detecting as significant
ment and was still registered without peri-implant disease at the at the 5% level.
KOLDSLAND and AASS | 1263

Descriptive statistics were performed using SPSS, Statistics 25 test-group implants). Subject characterization in test and control
(IBM®). Wilcoxon signed rank test was used to compare changes groups is presented in Table 1. Implant characteristics in test and
in the clinical parameters between baseline and the end of the fol- control group are presented in Table 2. The registered periodontal
low-up period. Independent sample t test was used to compare test parameters for the test and control group throughout the follow-up
and control groups within each time point. period are presented in Table 3.
All p-values below 0.05 (5%) were considered significant. In the test group, SPiT was performed at 61% of the implants at
the 6-month control and 75%, 81%, 82% and 79% of the implants
were in need of supportive treatment at the following examinations
3 | R E S U LT S (9, 12, 15 and 18 months postop.).
In the control group, SPiT was performed at 69% of the implants
Four implants (2.9%) in three subjects were withdrawn in the obser- at the 6-month postoperative control. At the following controls (9,
vation period: three implants at the 12-month postoperative exami- 12, 15 and 18 months postop.), 74%, 80%, 82% and 78% of the im-
nation and one at the 15-month examination. None of these subjects plants were given supportive treatment.
agreed to new surgery or explantation. For the purpose of statistical Assessment of basic maintenance or SPiT could be performed
calculations, the data from the day of exclusion were used to repre- at four time points: 9, 12, 15 and 18 months following surgery.
sent the implant throughout the follow-up period. All four implants The results according to the four clinical outcomes (Health sta-
withdrawn from study were from the control group. bility, Improvement, Impairment, Persisting disease) for the test
No adverse events were reported by the subjects participating and control group at the different time intervals are presented
in the study. in Table 4.
Randomization was performed at subject level (21 subjects in In the total population, 40.7% of the implants were registered as
each group, one subject not assigned to any group as no implant was Persisting disease at every time point (37.5% in the test group, 43.6%
registered with peri-implant disease during the observation period). in the control group).
As subjects might have more than one affected implant, an uneven When data including all implants (test and control groups) at
number of implants were assigned to each group (80 control-/55 every time point were pooled, 540 implant controls were performed

TA B L E 3 Clinical parameters for the

Time after 6 months 9 months 12 months 15 months 18 months
test and control groups in the follow-up
surgery (SD) (SD) (SD) (SD) (SD)
period
Clinical registrations
Plaque %
Test 14.3 (0.4) 31.3 (0.5) 34.6 (0.5) 48.2 (0.5) 42.9a (0.5)
Control 26.6 (0.4) 26.5 (0.4) 32.9 (0.5) 44.3 (0.5) 34.2 (0.5)
Control 13.9 (0.3) 23.5 (0.4) 32.9 (0.5) 31.6 (0.5) 21.5 (0.4)
Gingival bleeding %
Test 12.5 (0.3) 29.2 (0.5) 26.9 (0.4) 37.5 (0.5) 25.0 (0.4)
Control 13.9 (0.3) 23.5 (0.4) 32.9 (0.5) 31.6 (0.5) 21.5 (0.4)
PPD mean (mm)
Test 4.9 (1.2) 5.2 (1.6) 5.2b (1.6) 5.7 (1.7) 5.6a (1.6)
Control 5.0 (1.6) 5.3 (1.7) 5.9b (2.0) 5.7 (1.9) 5.7a (1.8)
PPD >3 mm %
Test 91.1 (0.3) 85.1 (0.4) 90.4 (0.3) 92.9 (0.3) 96.4 (0.3)
Control 83.3 (0.4) 92.5 (0.3) 93.6 (0.3) 94.9 (0.3) 97.4 (0.2)
BoP %
Test 80.4 (0.4) 91.5 (0.3) 92.3 (0.3) 91.1 (0.3) 85.7 (0.4)
Control 83.5 (0.4) 80.9 (0.4) 84.8 (0.4) 91.1 (0.3) 84.8 (0.4)
Suppuration %
Test 16.1 (0.4) 16.7 (0.4) 32.7 (0.5) 33.9 (0.5) 30.4a (0.5)
Control 17.7 (0.4) 27.9 (0.5) 29.5 (0.5) 34.2 (0.5) 24.1 (0.4)

Note: Implant level registrations; the most severe clinical registration at any site representing the
implant.
a
Statistically significant difference compared to 6-month results (Wilcoxon signed rank test).
b
Statistically significant difference between test and control groups (Independent sample t test).
1264 | KOLDSLAND and AASS

TA B L E 4 Percentage of implants
Pooled
registered with different clinical outcomes
Post-operative control 9 months 12 months 15 month 18 months data
following basic maintenance therapy/
Clinical outcome SPiT using chitosan brushes (test) or
Health stability (%) titanium curettes (control) in the follow-up
period (from 6 months up to 18 months
Test 17.9 12.5 7.1 7.1 11.4
post-surgery)
Control 17.9 11.5 7.7 9.0 11.3
Improvement (%)
Test 12.5 5.4 10.7 14.3 10.9
Control 9.0 9.0 10.3 11.5 9.7
Impairment (%)
Test 21.4 17.9 10.7 10.7 15.5
Control 12.8 15.4 12.8 9.0 12.2
Persisting disease (%)
Test 48.2 64.3 71.4 67.9 64.1
Control 60.3 64.1 69.2 70.5 64.4

Note: Pooled data from all time points shown in the column to the right.

(55 test implants and 80 control implants at 4 time points). Health radiographic bone loss, PPD >3 mm and inflammation) using chi-
stability was registered at 11.3% of the assessment, Improvement at tosan brushes have been described in a multicentre case series
10.2%, Impairment at 13.5%, and Persisting disease at 64.3% of the (Wohlfahrt et al., 2017). The implants were assessed 2 weeks,
assessments. The corresponding results segregated for test and con- 4 weeks, 3 months and 6 months following baseline treatment
trol groups are presented in Table 4. with repeated treatment at the 3 months assessment. Significant
At baseline (6 months postop), the mean bone level in the control reductions in both PPD and inflammation were seen at every time
group was registered 5.0 mm apically of the bone level at time of point relative to the baseline clinical measurement. Inflammation
implant loading (n = 72, max. 10.1 mm, min. 2.1 mm, SD 2.1). At the and PPD >3 mm was reported at 35% of the sites at the final ex-
18-month postop examination, the mean bone level was registered amination. These results showed a considerably better effect of
4.9 mm apically from the bone level at time of loading (n = 72, max treatment than the present study. There might be several rea-
12.1 mm, min. 1.4 mm, SD 2.1). The bone level change was not sta- sons for this. First of all, the subjects in the present study had
tistically significant. The mean bone level at baseline and 18 months received peri-implantitis surgery and the bone loss was more pro-
postoperatively in the test group was 5.1 mm (n = 53, max. 10.0 mm, nounced. The severity of bone loss has previously been described
min. 2.0 mm, SD 1.9) and 4.4 mm (n = 53, max. 8.8 mm, min. 1.0 mm, as a factor affecting the outcome of peri-implantitis treatment
SD 1.8). The bone level change was statistically significant. In the (Koldsland et al., 2018; Serino & Turri, 2011; de Waal et al., 2016).
test group, two implants were registered with extreme bone gain Furthermore, the difference in outcome might also be related to
(>5 mm) affecting the results in this group to a large extent. In the the inflammation criteria applied in the studies. In the present
test group, 38.9% of the implants were registered with >0.5 mm study, BoP was reported as a dichotomous positive/negative
bone gain versus. 38.6% in the control group. In the test group, variable. In the studies by Wohlfahrt and co-workers (Wohlfahrt
9.3% of the implants were registered with >0.5 mm bone loss versus et al., 2017, 2019), a graded bleeding index as proposed by Roos-
22.9% in the control group. Jansaker and co-workers (2007) was applied. Even though probing
No statistically significant difference was found between the around implants has been regarded as a good technique for as-
test and control groups. sessing the status of peri-implant mucosal health or disease, it has
been proposed that the soft tissue cuff around implants exhibits
less resistance to probing than the gingiva at teeth (Lang, Wetzel,
4 | D I S CU S S I O N Stich, & Caffesse, 1994). It has been discussed whether the pres-
sure from the probing instrument may lead to mechanically in-
In the present study, none of the supportive methods, curettes duced bleeding on probing on dental implants that are clinically
versus chitosan brushes, seemed to reduce the load of inflamma- healthy. A distinction between bleeding caused by trauma and
tion in the mucosa surrounding the implants diagnosed with peri- bleeding as an indication of inflammation has been proposed in a
implant disease. Reduction in inflammation using chitosan brushes report following the 2017 World Workshop on the Classification
in treatment of peri-implant mucositis has previously been re- of Periodontal and Peri-Implant Disease and Conditions. It was
ported (Wohlfahrt, Aass, & Koldsland, 2019). Also, favourable stated that bleeding “dots” should be interpreted carefully as this
results of non-surgical treatment of mild peri-implantitis (1-2 mm may represent bleeding due to tissue trauma (Renvert, Persson,
KOLDSLAND and AASS | 1265

Pirih, & Camargo, 2018). In the present study, no such distinction the peri-implant pocket with a disinfectant solution as a part of the
was made. Hence, the dichotomous registration of bleeding/no maintenance protocol could possibly have improved the outcome of
bleeding on probing from a peri-implant site might overestimate the procedures. A review by Schwarz, Schmucker, et al. (2015) stated
sites registered with inflammation and changes in the severity of though that adjunctive therapy (local and systemic antibiotics or me-
disease may be difficult to estimate. chanical [air abrasives]) may not improve the efficacy of profession-
Studies assessing non-surgical treatment of peri-implantitis using ally administered plaque removal in reducing BOP and PPD scores
curettes have reported similar results as the present study with only at peri-implant mucositis sites. Despite clinically important improve-
minor reduction of bleeding scores following treatment (Karring ments, a complete disease resolution may not be expected by any of
et al., 2005; Renvert et al., 2009). The combined use of several inter- the treatment protocols investigated. It is stated that peri-implant
ceptive non-surgical treatments such as titanium curettes and gly- tissue health can exist around implants with reduced bone support
cine-based powder air-polishing or photodynamic therapy has been (Berglundh et al., 2018) and the results of the present study sup-
reported, and still resolution of mucosal inflammation was rare at ported this statement, even though eradication of inflammation did
follow-up examinations (Schar et al., 2013). It has been reported that not seem a predictable outcome. Whether this can be achieved by
reduction in probing depth in the supportive phase following surgi- other means of SPiT or by the adjunctive use of chemical compo-
cal treatment (using ultrasonic with metal tips, with 0.12% chlorhex- nents when treatment of inflamed tissue with deep PPD following
idine irrigation) never was achieved for any of the residual pockets surgery is performed needs further investigation.
when SPiT was performed every 6 months (Serino et al., 2015). The results in the present study showed that although improve-
Only a few (2.9%) of the implants were withdrawn from the ment of the clinical parameters was present following surgery,
study during the first 18-month follow-up period. Even so, most eradication of inflammation was rare. In the follow-up period (6 to
implants were registered with inflammation throughout the fol- 18 months post-surgery), further improvement of clinical and ra-
low-up period. It is worth noticing that the percentage of implants diographic parameters was rare, although some implants were reg-
registered with plaque was high. The plaque score gradually istered with progressive bone gain during the follow-up period. A
increased in both test and control groups throughout the fol- statistically significant increase in mean bone level was observed
low-up period even though the subjects were instructed in oral in the test group. The reason for this was due to a substantial gain
hygiene repeatedly. Previous studies have reported a causal re- of bone at very few implants (two implants with >5 mm bone gain)
lationship between plaque control and peri-implant inflammation in this group. Hence, other factors rather than the SPiT procedure
(Pontoriero et al., 1994; Serino & Ström, 2009). Furthermore, me- could be the reason for this outcome. It is also possible that the
chanical non-surgical interventions have been shown ineffective methods used to assess inflammation overestimated peri-implant
for treatment of peri-implantitis in populations with poor oral hy- inflammation, as discussed above. To consider the effect of SPiT and
giene (Renvert et al., 2009), and there is reason to believe that this assess whether the bone level is stable, a longer observation time is
holds true for SPiT following surgery as well. needed.
In the present study, the effect of the treatment may have been In the present study, only hygiene instruction and rubber cup with
limited due to the designs and surfaces of the exposed threads. A pumice were used unless peri-implant disease was registered (PPD
recently published in vitro study assessed the surface changes at >3 mm with BoP/suppuration). When SPiT was performed, using
different parts of the implant threads when different mechanical titanium curettes or chitosan brushes, improvement of the clinical
decontamination tools were applied. The results indicated that cer- condition was achieved only on rare occasions (≈10%) and without
tain parts of threaded implants were difficult to reach by the use of any significant difference between test and control groups. Implants
mechanical instrumentation (Cha et al., 2019). The inability for in- registered with Improvement received only basic maintenance care.
struments to reach especially the “valley areas” and “apically facing” Implants receiving basic maintenance only were frequently regis-
thread surfaces of the implant threads may hamper the efficiency of tered with inflammation at the following examination, as shown as
the mechanical debridement of the implants, making it difficult to the outcome Impairment. The results in the present study indicated
eliminate bacterial biofilm formation (Cha et al., 2019; Steiger-Ronay that Persisting disease was the dominant outcome. Hence, prevention
et al., 2017). No other regimes than the use of titanium curette or of inflammation in addition to treatment of existing disease should
chitosan brush were used in addition to basic maintenance ther- be the focus of maintenance programmes following peri-implantitis
apy. The reason for this was the wish to test the ability of a rotating surgery. This highlights the difference between maintenance follow-
brush to improve the clinical conditions at implants registered with ing loading of a newly inserted implant, as described by Mombelli
peri-implant disease compared to the use of a curette at the anatom- (2019) and implant maintenance after treatment of peri-implantitis.
ically challenging surface of exposed implant threads. In the present In the present study, no statistically significant difference was
study, no difference was found between the two methods assessed. found between treatment protocols using titanium curettes or chitosan
This may indicate the need of more frequent SPiT and/or that the brushes. Eradication of disease was not a predictable end point, and the
subjects would have benefitted from additional treatment modali- clinical status deteriorated throughout the observation period. Within
ties. Other studies indicate the effect of disinfection methods in re- the limits of the present study, the results indicate the need of more
ducing bacterial load (Gosau et al., 2010). Hence, thorough rinsing of effective submucosal cleaning procedure after peri-implant surgery.
1266 | KOLDSLAND and AASS

C O N FL I C T O F I N T E R E S T cohort. Journal of Clinical Periodontology, 46(8), 872–879. https://doi.

org/10.1111/jcpe.13129
None of the authors declare a conflict of interest.
Karring, E. S., Stavropoulos, A., Ellegaard, B., & Karring, T.
(2005). Treatment of peri-implantitis by the Vector system.
ORCID Clinical Oral Implants Research, 16(3), 288–293. https://doi.
Odd Carsten Koldsland https://orcid.org/0000-0001-6842-8255 org/10.1111/j.1600-0501.2005.01141.x
Koldsland, O. C., Scheie, A. A., & Aass, A. M. (2010). Prevalence of
peri-implantitis – related to severity of the disease with different de-
REFERENCES grees of bone loss. Journal of Periodontology, 81(2), 231–238. https://
Armitage, G. C., & Xenoudi, P. (2016). Post-treatment supportive care for doi.org/10.1902/jop.2009.090269
the natural dentition and dental implants. Periodontology 2000, 71(1), Koldsland, O. C., Wohlfahrt, J. C., & Aass, A. M. (2018). Surgical treat-
164–184. https://doi.org/10.1111/prd.12122 ment of peri-implantitis: Prognostic indicators of short-term re-
Berglundh, T., Armitage, G., Araujo, M. G., Avila-Ortiz, G., Blanco, J., sults. Journal of Clinical Periodontology, 45(1), 100–113. https://doi.
Camargo, P. M., … Zitzmann, N. (2018). Peri-implant diseases and org/10.1111/jcpe.12816
conditions: Consensus report of workgroup 4 of the 2017 World Lang, N. P., Wetzel, A. C., Stich, H., & Caffesse, R. G. (1994). Histologic
Workshop on the Classification of Periodontal and Peri-Implant probe penetration in healthy and inflamed peri-implant tis-
Diseases and Conditions. Journal of Clinical Periodontology, 45(Suppl sues. Clinical Oral Implants Research, 5(4), 191–201. https://doi.
20), S286–s291. https://doi.org/10.1111/jcpe.12957 org/10.1034/j.1600-0501.1994.050401.x
Carcuac, O., Derks, J., Charalampakis, G., Abrahamsson, I., Wennstrom, Máximo, M. B., de Mendonça, A. C., Renata Santos, V., Figueiredo, L. C.,
J., & Berglundh, T. (2015). Adjunctive systemic and local antimicro- Feres, M., & Duarte, P. M. (2009). Short-term clinical and microbio-
bial therapy in the surgical treatment of peri-implantitis: A random- logical evaluations of peri-implant diseases before and after mechan-
ized controlled clinical trial. Journal of Dental Research, 95(1), 50–57. ical anti-infective therapies. Clinical Oral Implants Research, 20(1),
https://doi.org/10.1177/00220​3 4515​601961 99–108. https://doi.org/10.1111/j.1600-0501.2008.01618.x
Cha, J. K., Paeng, K., Jung, U. W., Choi, S. H., Sanz, M., & Sanz-Martin, Mombelli, A. (2019). Maintenance therapy for teeth and implants.
I. (2019). The effect of five mechanical instrumentation protocols Periodontology 2000, 79(1), 190–199. https://doi.org/10.1111/
on implant surface topography and roughness: A scanning elec- prd.12255.
tron microscope and confocal laser scanning microscope analysis. Mombelli, A., van Oosten, M. A., Jr, S. E., & Lang, N. P. (1987). The micro-
Clin Oral Implants Res, 30(6), 578–587. https://doi.org/10.1111/ biota associated with successful or failing osseointegrated titanium
clr.13446 implants. Oral Microbiology and Immunology, 2(4), 145–151. https://
de Waal, Y. C., Raghoebar, G. M., Meijer, H. J., Winkel, E. G., & van doi.org/10.1111/j.1399-302X.1987.tb002​98.x
Winkelhoff, A. J. (2016). Prognostic indicators for surgical peri-im- Pontoriero, R., Tonelli, M. P., Carnevale, G., Mombelli, A., Nyman, S. R.,
plantitis treatment. Clinical Oral Implants Research, 27(12), 1485– & Lang, N. P. (1994). Experimentally induced peri-implant mucositis.
1491. https://doi.org/10.1111/clr.12584 A clinical study in humans. Clinical Oral Implants Research, 5(4), 254–
Derks, J., Schaller, D., Hakansson, J., Wennstrom, J. L., Tomasi, C., & 259. https://doi.org/10.1034/j.1600-0501.1994.050409.x
Berglundh, T. (2016). Effectiveness of implant therapy analyzed Renvert, S., Persson, G. R., Pirih, F. Q., & Camargo, P. M. (2018). Peri-
in a Swedish population: Prevalence of peri-implantitis. Journal of implant health, peri-implant mucositis, and peri-implantitis: Case
Dental Research, 95(1), 43–49. https://doi.org/10.1177/00220​3 4515​ definitions and diagnostic considerations. Journal of Clinical
608832 Periodontology, 45(Suppl 20), S278–s285. https://doi.org/10.1111/
Faggion, C. M. Jr, Listl, S., Fruhauf, N., Chang, H. J., & Tu, Y. K. (2014). jcpe.12956
A systematic review and Bayesian network meta-analysis of ran- Renvert, S., Polyzois, I., & Claffey, N. (2012). Surgical therapy for the
domized clinical trials on non-surgical treatments for peri-implanti- control of peri-implantitis. Clinical Oral Implants Research, 23(Suppl
tis. Journal of Clinical Periodontology, 41(10), 1015–1025. https://doi. 6), 84–94. https://doi.org/10.1111/j.1600-0501.2012.02554.x
org/10.1111/jcpe.12292 Renvert, S., Samuelsson, E., Lindahl, C., & Persson, G. R. (2009).
Gosau, M., Hahnel, S., Schwarz, F., Gerlach, T., Reichert, T. E., & Burgers, Mechanical non-surgical treatment of peri-implantitis: A dou-
R. (2010). Effect of six different peri-implantitis disinfection methods ble-blind randomized longitudinal clinical study. I: clinical results.
on in vivo human oral biofilm. Clinical Oral Implants Research, 21(8), Journal of Clinical Periodontology, 36(7), 604–609. https://doi.
866–872. https://doi.org/10.1111/j.1600-0501.2009.01908.x org/10.1111/j.1600-051X.2009.01421.x.
Heitz-Mayfield, L. J., Needleman, I., Salvi, G. E., & Pjetursson, B. E. (2014). Roos-Jansåker, A. M., Lindahl, C., Renvert, H., & Renvert, S. (2006). Nine-
Consensus statements and clinical recommendations for prevention to fourteen-year follow-up of implant treatment. Part II: Presence
and management of biologic and technical implant complications. of peri-implant lesions. Journal of Clinical Periodontology, 33(4),
International Journal of Oral and Maxillofacial Implants, 29(Suppl), 290–295.
346–350. http://dx.doi.org/10.11607/​jomi.2013.g5 Roos-Jansaker, A. M., Renvert, H., Lindahl, C., & Renvert, S. (2007).
Heitz-Mayfield, L. J., Salvi, G. E., Botticelli, D., Mombelli, A., Faddy, Surgical treatment of peri-implantitis using a bone substitute with
M., & Lang, N. P.; Group, I. C. R (2011). Anti-infective treat- or without a resorbable membrane: A prospective cohort study.
ment of peri-implant mucositis: A randomised controlled clinical Journal of Clinical Periodontology, 34(7), 625–632. https://doi.
trial. Clinical Oral Implants Research, 22(3), 237–241. https://doi. org/10.1111/j.1600-051X.2007.01102.x
org/10.1111/j.1600-0501.2010.02078.x Salvi, G. E., & Ramseier, C. A. (2015). Efficacy of patient-administered
Heitz-Mayfield, L. J., Salvi, G. E., Mombelli, A., Loup, P. J., Heitz, F., mechanical and/or chemical plaque control protocols in the manage-
Kruger, E., & Lang, N. P. (2016). Supportive peri-implant therapy ment of peri-implant mucositis. A systematic review. Journal of Clinical
following anti-infective surgical peri-implantitis treatment: 5-year Periodontology, 42, S187–S201. https://doi.org/10.1111/jcpe.12321
survival and success. Clinical Oral Implants Research, https://doi. Schar, D., Ramseier, C. A., Eick, S., Arweiler, N. B., Sculean, A., & Salvi, G.
org/10.1111/clr.12910 E. (2013). Anti-infective therapy of peri-implantitis with adjunctive
Karlsson, K., Derks, J., Hakansson, J., Wennstrom, J. L., Petzold, M., & local drug delivery or photodynamic therapy: Six-month outcomes of
Berglundh, T. (2019). Interventions for peri-implantitis and their ef- a prospective randomized clinical trial. Clinical Oral Implants Research,
fects on further bone loss: A retrospective analysis of a registry-based 24(1), 104–110. https://doi.org/10.1111/j.1600-0501.2012.02494.x
KOLDSLAND and AASS | 1267

Schwarz, F., Becker, K., & Sager, M. (2015). Efficacy of professionally Steiger-Ronay, V., Merlini, A., Wiedemeier, D. B., Schmidlin, P. R., Attin,
administered plaque removal with or without adjunctive measures T., & Sahrmann, P. (2017). Location of unaccessible implant surface
for the treatment of peri-implant mucositis. A systematic review areas during debridement in simulated peri-implantitis therapy. BMC
and meta-analysis. Journal of Clinical Periodontology, 42, S202–S213. Oral Health, 17(1), 137. https://doi.org/10.1186/s1290​3-017-0428-8
https://doi.org/10.1111/jcpe.12349 Wohlfahrt, J. C., Aass, A. M., & Koldsland, O. C. (2019). Treatment of
Schwarz, F., Schmucker, A., & Becker, J. (2015). Efficacy of alternative or peri-implant mucositis with a chitosan brush-A pilot randomized
adjunctive measures to conventional treatment of peri-implant mu- clinical trial. International Journal of Dental Hygiene, 17(2), 170–176.
cositis and peri-implantitis: a systematic review and meta-analysis. https://doi.org/10.1111/idh.12381
International Journal of Implant Dentistry, 1. https://doi.org/10.1186/ Wohlfahrt, J. C., Evensen, B. J., Zeza, B., Jansson, H., Pilloni, A., Roos-
s40729-015-0023-1 Jansåker, A. M., … Koldsland, O. C. (2017). A novel non-surgical
Serino, G., & Ström, C. (2009). Peri-implantitis in partially edentu- method for mild peri-implantitis- a multicenter consecutive case
lous patients: Association with inadequate plaque control. Clinical series. International Journal of Implant Dentistry, 3(1), 38. https://doi.
Oral Implants Research, 20(2), 169–174. https://doi.org/10.1111/j org/10.1186/s4072​9-017-0098-y
.1600-0501.2008.01627.x
Serino, G., & Turri, A. (2011). Outcome of surgical treatment of peri-im-
plantitis: Results from a 2-year prospective clinical study in humans.
How to cite this article: Koldsland OC, Aass AM. Supportive
Clinical Oral Implants Research, 22(11), 1214–1220. https://doi.
org/10.1111/j.1600-0501.2010.02098.x
treatment following peri-implantitis surgery: An RCT using
Serino, G., Turri, A., & Lang, N. P. (2015). Maintenance therapy in patients titanium curettes or chitosan brushes. J Clin Periodontol.
following the surgical treatment of peri-implantitis: A 5-year fol- 2020;47:1259–1267. https://doi.org/10.1111/jcpe.13357
low-up study. Clinical Oral Implants Research, 26(8), 950–956. https://
doi.org/10.1111/clr.12418