Background
Methods
Focused questions
Objectives
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To determine and compare clinical outcomes of debridement using APDs compared to hand scaling and/or power-driven instruments in SPT and implant maintenance patients,
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To determine and compare patients’ perception during treatment with APDs in comparison to hand scaling and/or power-driven instruments in SPT and implant maintenance patients,
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To determine and compare the cost-effectiveness of APDs compared to hand scaling and/or power-driven instruments in SPT and implant maintenance patients.
PICO for focused question 1
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Population: SPT patients, aged ≥ 18 years, with good systemic health or controlled systemic diseases
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Intervention: Use of APDs for non-surgical supra- and/or subgingival therapy
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Comparison: Conventional hand or sonic/ultrasonic instruments or a combination of both
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Outcomes: Primary outcomes were assessment on changes of clinical parameters such as Probing Pocket Depth (PPD), Clinical Attachment Level (CAL) and Bleeding on Probing (BOP). Secondary outcomes were Patient Reported Outcome Measures (PROMs) in terms of Visual Analogue Scale (VAS) score, questionnaires on Quality of Life (QoL) or patient interview, as well as economic evaluation using cost effectiveness analysis, cost utility analysis or cost benefit analysis.
PICO for focused question 2
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Population: Implant maintenance patients, aged ≥ 18 years, with good systemic health or controlled systemic diseases
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Intervention: Use of APDs for non-surgical supra- and/or subgingival therapy
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Comparison: Conventional hand or sonic/ultrasonic instruments or a combination of both
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Outcomes: Primary outcomes were assessment on changes of clinical parameters such as PPD, CAL and BOP. Secondary outcomes were PROMs in terms of VAS score, questionnaires on QoL or patient interview, as well as economic evaluation using cost effectiveness analysis, cost utility analysis or cost benefit analysis.
Types of studies
Inclusion criteria
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RCTs in SPT phase (focused question 1) or implant maintenance programme (focused question 2).
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Adult subjects of ≥ 18 years of age.
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Individuals in good systemic health or controlled systemic diseases.
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Intervention / test group using APDs; control with hands instrumentation and/or sonic/ultrasonic scalers.
Exclusion criteria
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Lack of repeated interventions or retreatment in periodic recall visits.
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Pregnant and lactating females.
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Antibiotic usage within the last four weeks before the trial.
Search strategy
Study selection
Unclear or missing data
Data extraction and management
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First author’s name and year of publication, study location (country).
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Study population including setting, number of patients, mean age, gender, and smoking status.
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Study design, duration of follow-up and case definition of study sites, if any.
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Details on the treatment groups/interventions, including but not limited to:
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Type of powder used, with or without special nozzle.
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Type of conventional instrument.
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Time allocation on each site.
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Retreatment interval.
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Details of included variables such as clinical parameters, patient reported outcome measures (PROMs), economic evaluation as well as timepoints of assessment.
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Details of corresponding treatment outcomes.
Quality assessment
Data synthesis
Results
Search
Reasons for exclusion | SPT studies |
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In Chinese | Hu et al. [31] |
In Chinese | Zhao et al. [32] |
In German | Moene et al. [33] |
Same cohort as one of the included studies—pilot study | Kruse et al. [34] |
Lack of information on clinical data | Petersilka et al. [35] |
Lack of information on clinical data | Petersilka et al. [36] |
Lack of repeated interventions / retreatment | Flemmig et al. [12] |
Lack of repeated interventions / retreatment | Hagi et al. [37] |
Lack of repeated interventions / retreatment | Lu et al. [16] |
Lack of repeated interventions / retreatment | Lu et al. [38] |
Lack of repeated interventions / retreatment | Moene et al. [10] |
Lack of repeated interventions / retreatment | Simon et al. [39] |
Lack of repeated interventions / retreatment | Wennstrom et al. [20] |
Control group using water irrigation only | Sekino et al. [40] |
Reasons for exclusion | Maintenance studies |
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Book chapter | Monje et al. [41] |
In German | Petersilka et al. [42] |
Observational study with no comparator | Duarte et al. [43] |
Observational study with no comparator | Heitz-Mayfield et al. [44] |
Treatment of peri-implant diseases | Al Ghazal et al. [11] |
Treatment of peri-implant diseases | Schmidt et al. [19] |
In vitro study | Koishi et al. [45] |
Lack of repeated interventions / retreatment | Menini et al. [46] |
Lack of repeated interventions / retreatment | Mussano et al. [47] |
Study characteristics
Study | Population | Study design | Treatment groups | Variables | Treatment outcome |
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Hagi et al. [13] | Setting: University | RCT | Test: EPAP with a single-use nozzle (5 s each site) | Primary: Site-specific BOP | Mean BOP: |
Parallel | Test = 40.45%; Control = 42.53% | ||||
40 SPT subjects | Examiner-masked | Clinical: Full mouth and site-specific PI, BOP, PPD and CAL | |||
Switzerland | (38 completed study) | Control: Hand instruments only, no time limit | Mean PPD reduction: | ||
Duration: 6 months | Test = 0.67 mm; Control = 0.68 mm | ||||
Mean age: 54.5 y | Safety assessment: Adverse events at every visit by clinical examination and patient interview | ||||
Gender: 15 F, 25 M | Study sites: BOP and PPD of ≥ 4 mm without presence of detectable subgingival calculus, exclude furcation involved and adjacent test sites | Without local anaesthesia | EPAP and curettes resulted in significant but similar reductions of clinical parameters. No statistical difference between both groups for site specific BOP, PPD and CAL | ||
Retreatment: 3-month | |||||
Smoking status: Included but not detailed | Timepoints: Baseline, 6-month | No adverse events reported | |||
Kargas et al. [14] | Setting: University | RCT | Negative control: | Primary: PPD change | Mean PPD reduction: |
Split mouth | 1) Subgingival GPAP—5 s per site | GPAP = 0.26 mm; UD = 0.66 mm; SRP = 0.44 mm | |||
25 SPT subjects | Blinding not mentioned | Clinical: PPD, CAL, GR, GI, PI | |||
Greece | 2) Subgingival ultrasonic debridement (UD) | ||||
Mean age: 52.5 y | Duration: 6 months | PROMs: Pain perception, cold or pressure (questionnaire at baseline after treatment) | GPAP group had significantly higher PPD than the SRP group at 1,3 and 6 months and higher level of CAL at 1 month. No differences among groups for GR, GI and PI | ||
3) No further subgingival treatment | |||||
Gender: 10 F, 15 M | Study site: No BOP and PPD > 4 mm, furcation not specified as an exclusion criterion | ||||
Positive control: Subgingival scaling with hand instruments (SRP) | |||||
Smoking status: Non-smoker | Timepoints: baseline, 1-, 3- and 6-month | ||||
Less pain, no sense of pressure with GPAP | |||||
Retreatment: 3-month | |||||
Kruse et al. [15] | Setting: University | RCT | Test: APD with trehalose powder and single-use nozzle (total 20 s) | Primary: PPD change | Mean PPD reduction: |
Split mouth | Test = 1.86 mm; Control = 1.87 mm | ||||
44 SPT subjects | Examiner-masked | Clinical: PPD, CAL, GR, BOP, PI, SBI | |||
Germany | APD and sonic device resulted in significant intra-group reduction of PPD, CAL and BOP after 6 months with no significant inter-group differences | ||||
Mean age: 59.7 y | Duration: 6 months | Control: Sonic scaler (total 20 s) | |||
PROMs: VAS score after treatment for each procedure | |||||
Gender: 18 F, 26 M | Study site: Single-rooted teeth with PPD 5 mm and BOP or PPD > 5 mm ± BOP | ||||
Retreatment: 3-month | |||||
Smoking status: Included but not detailed | Timepoints: Baseline, 3- and 6-month | A significant lower incidence of discomfort for air polishing compared to sonic scaling | |||
Muller et al. [18] | Setting: University | RCT | Test: EPAP with a single-use nozzle (5 s each site) | Primary: Presence or absence of PPD > 4 mm per subject | Mean n sites with PD > 4 mm: |
Split mouth | Test = 3.6; Control = 3.9 | ||||
50 SPT subjects | Examiner-masked | ||||
Switzerland | (49 completed study) | Control: Ultrasonic scaler (20 s per site) | Clinical: PPD, GR, BOP, PI, root hypersensitivity | The number of pockets > 4 mm per subject, PPD and BOP were significantly lower at month 12 with no significant difference between EPAP therapy and ultrasonic debridement | |
Duration: 12 months | |||||
Mean age: 58.5 y | |||||
Study site: PPD > 4 mm with absence of clinically detectable subgingival calculus, furcation not specified as an exclusion criterion | Retreatment: 3-, 6- and 9-month | PROMs: VAS score after each procedure | |||
Gender: 29 F, 21 M | |||||
Smoking status: Included but not detailed | Timepoints: Baseline and 12-month | A significant difference in favour of air-polishing for pain / discomfort |
Study | Population | Study design | Case definition | Treatment groups | Variables | Treatment outcome |
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Lupi et al. [17] | Setting: University | RCT | No signs of inflammation or mucositis | Test: GPAP with Perio-Flow nozzle (5 s each site) | Primary: PPD change | Mean PPD reduction: Test = 0.64 mm; Control = − 0.31 mm |
Parallel | ||||||
46 subjects (35 partial; 11 total edentulism) with 88 implants | Examiner-masked | No PPD ≥ 4 mm and suppuration; No bone resorption ≥ 30% compared to initial situation; No implant mobility | Clinical: PI, BOP, PPD, CAL, bleeding score | |||
Italy | Control: Plastic curettes + irrigation with 0.1% CHX + submucosal application 1% CHX gel | GPAP statistically improved PPD, PI, BOP and bleeding score after 6 months; more effective than Control in maintaining the peri-implant health of PPD. No significant changes of CAL in both groups | ||||
Duration: 6 months | ||||||
Mean age: 54.2 y | PROMs: Not reported | |||||
Gender: Not reported | Without local anaesthesia | |||||
Timepoints: Baseline, 3- and 6-month | ||||||
Smoking status: Non-smokers | At least 2 mm keratinized peri-implant mucosa | Retreatment: at monthly basis | ||||
Ziebolz et al. [21] | Setting: Multicentre study (7 dental practices) | RCT | Not specified | Test (Adjunctive AP): | Primary: Not reported | No significant implant-related differences in PPD, MR and BOP in group 2), 3) and 4) between baseline and follow-up, while group 2) showed a significant difference in PPD |
Parallel | 1) Curette + GPAP + prophylaxis brush | |||||
Masking not mentioned | Study began after prosthetic restoration of a previously inserted implant with no signs of inflammation, no previous non-surgical or surgical therapy | Clinical: Papillary bleeding index, approximal PI, PPD, MR, BOP | ||||
Germany | 62 subjects (partially or fully edentulous) with 101 implants | 2) Curette + GPAP + prophylaxis brush + CHX varnish | ||||
Duration: 12 months | ||||||
Mean age: 55.21 ± 11.3 y | Control (Adjunctive Sc): | PROMs: Not reported | ||||
3) Curette + sonic scaler + prophylaxis brush | ||||||
Timepoints: baseline and 12-month | ||||||
Gender: 27 F, 35 M | 4) Curette + sonic scaler + polishing with prophylaxis brush + CHX varnish | |||||
Smoking status: Non-smoker | ||||||
Retreatment: 3-, 6-, 9-month |
Sample characteristics
Risk of bias and methodologic quality
Primary outcomes comparison: clinical parameters
Secondary outcomes comparison
Parameter | Study | Intervention / | Total | Baseline / | P | Follow up / mean (SD) | |||||
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comparator(s) | mean (SD) | 3-month | P | 6-month | P | 12-month | P | ||||
Mean PPD | Hagi et al. [13] | APD (EPAP) | 91 | 4.46 (0.67) | > 0.05 | 3.78 (1.23) | > 0.05 | ||||
(mm) | Curettes | 96 | 4.65 (0.88) | 3.92 (1.40) | |||||||
Kargas et al. [14] | APD (GPAP) | 25 | 4.78 (0.50) | NS | 4.40 (0.55) | 4.52 (0.45) | |||||
Ultrasonics | 25 | 4.66 (0.50) | 3.84 (0.35) | * | 4.00 (0.40) | * | |||||
Curettes | 25 | 4.50 (0.45) | 3.70 (0.40) | * | 4.06 (0.50) | * | |||||
Kruse et al. [15] | APD (TPAP) | 44 | 5.52 (0.93) | NS | 4.25 (1.12) | > 0.05 | 3.66 (0.81) | > 0.05 | |||
Sonic | 44 | 5.55 (0.90) | 4.11 (1.08) | 3.68 (0.86) | |||||||
Muller et al. [18] | APD (EPAP) | 50 | 5.2 (0.4) | 0.003 | 4.5 (1.0) | NS | |||||
Ultrasonics | 50 | 5.4 (0.6) | 4.4 (1.1) | ||||||||
Mean CAL | Hagi et al. [13] | APD (EPAP) | 91 | 4.90 (1.81) | > 0.05 | 4.43 (2.26) | > 0.05 | ||||
(mm) | Curettes | 96 | 5.07 (2.06) | 4.37 (2.43) | |||||||
Kargas et al. [14] | APD (GPAP) | 25 | 5.42 (0.65) | 5.38 (0.60) | 5.40 (0.55) | ||||||
Ultrasonics | 25 | 5.12 (0.55) | NS | 4.76 (0.55) | * | 4.82 (0.55) | * | ||||
Curettes | 25 | 4.94 (0.45) | * | 4.84 (0.45) | * | 4.82 (0.45) | * | ||||
Kruse et al. [15] | APD (TPAP) | 44 | 6.93 (1.50) | NS | 5.80 (1.65) | > 0.05 | 5.30 (1.52) | > 0.05 | |||
Sonic | 44 | 7.27 (1.80) | 6.00 (1.73) | 5.84 (1.71) | |||||||
BOP (%) | Hagi et al. [13] | APD (EPAP) | FM | 31.70 (14.24) | > 0.05 | 26.11 (17.88) | > 0.05 | ||||
36.45 (17.51) | 27.89 (15.53) | ||||||||||
Kruse et al. [15] | APD (TPAP) | T | 86.36 | NS | 59.09 | < 0.001 | 40.91 | < 0.001 | |||
Sonic | 88.64 | 63.64 | 34.09 | ||||||||
Muller et al. [18] | APD (EPAP) | S | 58 (50) | NS | 31 (47) | NS | |||||
Ultrasonics | 48 (50) | 27 (45) | |||||||||
VAS (1–10) | Kruse et al. [15] | APD (TPAP) | 2.33 (2.14) | < 0.001 | |||||||
Sonic | 4.91 (2.65) | ||||||||||
Muller et al. [18] | APD (EPAP) | 2.04 (2.17) | 0.004 | ||||||||
Ultrasonics | 4.86 (2.92) |
Parameter | Study | Intervention/comparator(s) | Total | Baseline/mean (SD) | P | Follow up/mean (SD) | |||||
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3-month | P | 6-month | P | 12-month | P | ||||||
Mean PPD | Lupi et al. [17] | GPAP | 24 | 2.51 (0.24) | NS | 2.19 (0.35) | < 0.05 | 1.87 (0.38) | < 0.001 | ||
(mm) | MDA | 22 | 2.39 (0.46) | 2.54 (0.48) | 2.70 (0.37) | ||||||
Ziebolz et al. [21] | Adjunctive GPAP | 45 | 1.77 (1.58) | NR | 2.31 (1.54) | NR | |||||
Adjunctive GPAP + CHX | 37 | 2.00 (1.38) | 2.05 (1.32) | ||||||||
Adjunctive Sc | 36 | 1.75 (1.23) | 2.21 (1.32) | ||||||||
Adjunctive Sc + CHX | 49 | 2.67 (1.63) | 2.23 (1.28) | ||||||||
Mean CAL | Lupi et al. [17] | GPAP | 24 | 1.06 (1.07) | NS | 1.03 (1.09) | NS | 0.89 (1.04) | NS | ||
(mm) | MDA | 22 | 0.55 (0.87) | 0.63 (0.94) | 0.74 (0.96) | ||||||
BOP (%) | Lupi et al. [17] | GPAP | I | 45.83 (39.47) | < 0.001 | 33.33 (32.69) | 0.05 | 20.83 (30.99) | < 0.01 | ||
MDA | 84.09 (25.05) | 71.59 (27.05) | 70.45 (26.32) | ||||||||
Ziebolz et al. [21] | Adjunctive GPAP | I | 11.5 | NR | 11.5 | NR | |||||
Adjunctive GPAP + CHX | 4.8 | 1 | |||||||||
Adjunctive Sc | 0 | 4.2 | |||||||||
Adjunctive Sc + CHX | 0 | 100.25 |
Meta-analysis of primary outcomes
Discussion
Key findings in SPT studies
Clinical parameters
Patient reported outcomes
Key findings in implant maintenance studies
Clinical parameters
Overall completeness and applicability of the evidence
Absence of economic data
Lack of repeated evaluation of patients’ perception
Insufficient information on APDs for implant maintenance
Overall quality, strength and consistency of the evidence
Limitations of included studies
Strengths of the review
Potential biases in the review process
Implications for practice and policy
Implications for future research
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Population and study design
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To exclude current smokers from the studies.
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To investigate effects of repeated intervention with longer follow-up duration of at least 12-month.
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Objectives
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To standardise assessment of clinical parameters.
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To include microbiological assessment to support clinical outcomes.
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To conduct economic evaluation on types of treatment modality used.
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To investigate the effects on multi-rooted teeth with or without furcation involvement.
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To assess patients’ comfort by using VAS scale as a tool at multiple intervals.
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To assess tooth/implant loss (survival rate) as one of the tangible outcomes.
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