Received: 26 August 2021 Revised: 1 May 2022 Accepted: 6 May 2022

DOI: 10.1111/jcpe.13663

ORIGINAL ARTICLE

Adjuvant use of multispecies probiotic in the treatment

of peri-implant mucositis: A randomized controlled trial

Sandro I. Santana1 | Pedro H. F. Silva1 | Sérgio L. Salvador2 |

3 1
Renato C. V. Casarin | Flávia A. C. Furlaneto | Michel R. Messora1

1
Department of Oral and Maxillofacial Surgery
and Periodontology, School of Dentistry of
Ribeirao Preto, University of Sao Paulo—USP,
Ribeirao Preto, São Paulo, Brazil
2 multispecies probiotic containing Lactobacillus rhamnosus HN001™, Lactobacillus
Department of Clinical Analyses, School of
Pharmaceutical Sciences of Ribeirao Preto,
University of São Paulo—USP, Ribeirão Preto,
São Paulo, Brazil
3
Department of Prosthodontics and
Periodontics, School of Dentistry, Campinas
State University—UNICAMP, Piracicaba, São
Paulo, Brazil
Correspondence
Flávia A. C. Furlaneto, Av. Café s/n, Ribeirão
Preto, SP 14020-150, Brazil.
Email: flafurlaneto@usp.br
Abstract
Aim: This randomized placebo-controlled clinical trial evaluated the effects of
paracasei Lpc-37®, and Bifidobacterium animalis subsp lactis HN019™ as an adjunct to
mechanical debridement (MD) on changes in bleeding on probing (BOP) in
edentulous patients with peri-implant mucositis (PiM).
Materials and Methods: Patients were randomly assigned to test (probiotic) or
control (placebo) groups. All sites with PiM received MD and topical gel application
(probiotic or placebo) at baseline and 12 weeks. After initial MD, patients consumed
probiotic or placebo capsules twice a day for 12 weeks. Clinical (modified sulcus
bleeding index [mSBI]; modified plaque index [mPI]; probing depth [PD]; and BOP)
and immunological parameters were collected at baseline and after 12 and 24 weeks.
Data were statistically analysed (p < .05).
Results: Thirty-six patients with PiM were recruited. The test group presented
higher prevalence (p < .05) of cases of restored peri-implant health at 24 weeks
than did the control group (72.2% and 33.3%, respectively). No significant differ-
ence was observed between test (n = 18) and control (n = 18) groups for mPI and
PD. mSBI %—score 0 was higher in the test group than in the control group at
24 weeks (p < .05). When compared with baseline, both groups presented
reduced BOP at 12 and 24 weeks (p < .05). BOP was lower in the test group than
in the control group at 12 (mean difference =
14.54%; 95% confidence interval
[CI] =
28.87 to 0.22; p = .0163) and 24 (mean difference =
12.56%; 95%
CI =
26.51 to 1.37; p = .0090) weeks. At 24 weeks, only the test group pres-
ented lower levels of interleukin (IL)-1β, IL-6, IL-8, and tumour necrosis factor
(TNF)-α than those at baseline (p < .05).
Conclusions: The multispecies probiotic (administered locally and systemically) con-
taining L. rhamnosus HN001™, L. paracasei Lpc-37®, and B. lactis HN019™ as an
adjunct to repeated MD promotes additional clinical and immunological benefits in
the treatment of PiM in edentulous patients (ClinicalTrials.gov NCT04187222).

KEYWORDS
dental implant, mucositis, probiotic

828 © 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. wileyonlinelibrary.com/journal/jcpe J Clin Periodontol. 2022;49:828–839.
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SANTANA ET AL. 829

Clinical Relevance
Scientific rationale for the study: Conventional mechanical treatment may not completely elimi-
nate peri-implant diseases. Probiotics have demonstrated to be a potential therapy.
Principal findings: Adjunctive use of probiotics containing L. rhamnosus HN001TM, L. paracasei
Lpc-37®, and B. lactis HN019TM in the treatment of peri-implant mucositis in edentulous
patients results in a significantly higher prevalence of cases of peri-implant health at 24 weeks.
Practical implications: Probiotics containing L. rhamnosus HN001TM, L. paracasei Lpc-37®, and B.
lactis HN019TM as adjuncts to mechanical debridement may be an important therapeutic strat-
egy in the treatment of peri-implant mucositis.

1 | I N T RO DU CT I O N
Peri-implant mucositis (PiM) is characterized by mucosal inflammation
around implants, with bleeding on probing (BOP) and/or suppuration on
probing, with or without clinical signs of inflammation, such as erythema
and oedema, around a prosthetic component (Yu et al., 2016; Berglundh
et al., 2018). Considering the patient as a statistical unit, the prevalence of
PiM was estimated at 43% (Derks & Tomasi, 2015; C.-T. Lee et al., 2017).
PiM may be a precursor stage of peri-implantitis (Heitz-Mayfield
et al., 2011; Lang, Bosshardt, & Lulic, 2011). Therefore, early diagnosis
and intervention are of utmost clinical importance in the management
of peri-implant infections (Ji et al., 2014). The primary objective of
treating peri-implant diseases is to eliminate biofilms from the implant
surface. Few clinical studies have assessed protocols for the treatment
of PiM (Heitz-Mayfield & Lang, 2004; Renvert et al., 2008; Maximo
et al., 2009; Thone-Muhling et al., 2010; Heitz-Mayfield et al., 2011).
Even though clinical parameters can be improved by mechanical
debridement (MD), sites with deeper pockets and BOP are still
observed after the treatment (Heitz-Mayfield et al., 2011). Ancillary
methods, including the use of mouthwash, application of local antisep-
tic gel, use of antimicrobial photodynamic therapy, systemic antibi-
otics, and air abrasion device, have not provided additional benefits
when compared with conventional mechanical treatment (Ciancio
et al., 1995; Porras et al., 2002; Lindhe & Meyle, 2008; Thone-
Muhling et al., 2010; Heitz-Mayfield et al., 2011; Hallström
et al., 2012; Jepsen et al., 2015; Albaker et al., 2018; Barootchi
et al., 2020; Liu et al., 2020; Ramanauskaite et al., 2021).
Probiotics are “live microorganisms that, when administered in
adequate amounts, confer a health benefit on the host” (Hill
et al., 2014). The literature has provided some compelling evidence
concerning the use of beneficial bacterial strains as a therapeutic
strategy against periodontal diseases (Gruner et al., 2016; Martin-
Cabezas et al., 2016). Favourable results have been demonstrated in
several studies that evaluated the effects of probiotics on gingivitis, a
disease that is similar to PiM (Krasse et al., 2006; Staab et al., 2009;
Twetman et al., 2009; Harini & Anegundi, 2010; Iniesta et al., 2012;
Hallström et al., 2013; J. K. Lee et al., 2015; Nadkerny et al., 2015).
Regarding peri-implant diseases, especially PiM, there is a paucity of
studies on the effects of probiotics (only six studies), and these studies rev-
ealed contradictory results (Flichy-Fernandez et al., 2015; Hallström
et al., 2016; Mongardini et al., 2017; Galofré et al., 2018; Alqahtani
et al., 2019; Peña et al., 2019). Moreover, these studies investigated only
the effects of microorganisms of the genus Lactobacillus. Other potential
probiotics, such as those of the genus Bifidobacterium, should be assessed
as well. Studies on the effects of probiotics on periodontal diseases have
demonstrated the benefits of bacteria of the genus Bifidobacterium (Kuru
et al., 2017; Invernici et al., 2018). It should be highlighted that the effects
of probiotics on oral health depend on the strain used.
This randomized placebo-controlled clinical trial evaluated the
effects of multispecies probiotic (Bifidobacterium animalis subsp lactis
HN019™, Lactobacillus rhamnosus HN001™, and Lactobacillus paracasei
Lpc-37®) as an adjunct to MD on changes in BOP in edentulous
patients with PiM.
2 | M A T E R I A L S A N D M ET H O D S
2.1 | Ethical aspects
The procedures carried out in this study were approved by the Research
Ethics Committee (protocol number 82840117.4.0000.5419) of the
School of Dentistry of Ribeirao Preto—University of Sao Paulo (FORP-
USP, Ribeirao Preto, Brazil). The study was registered at ClinicalTrials.gov
(NCT04187222). Patients were recruited from July 2018 to February
2019 at Sul de Minas Center for Oral Maxillofacial Surgery (Paraguaçu,
Brazil). Sample size was estimated in order to provide an 80% power to
detect a significant 25% difference (Galofré et al., 2018) on changes in
BOP between the assessed groups using a 99% confidence interval
(α = .01) and a SD of 24% (Galofré et al., 2018). Therefore, 36 patients
were necessary for the study, considering a 35% dropout rate.
2.2 | Inclusion and exclusion criteria
The inclusion criteria were as follows: (i) completely edentulous
individuals with lower or upper arch rehabilitated with dental
implants; (ii) functional prosthetic restoration for at least
12 months; (iii) healthy individuals, without any known systemic
disorder; and (iv) non-smokers.
The selected patients had at least one dental implant with PiM.
Implants with PiM should present BOP at one or more sites and/or
suppuration in the absence of crestal bone at 3 mm or more away

830
from the most coronal portion of the intraosseous part of the implant
(Berglundh et al., 2018).
The exclusion criteria were as follows: (i) individuals who had
received any type of local or systemic decontamination of the oral
cavity in the past 3 months (MD or use of local or systemic antimicro-
bials/anti-inflammatory drugs); (ii) individuals with malpositioned
implants or implants placed in grafted areas.
2.3 | Experimental design, allocation concealment,
and treatment protocol
The selected patients were identified by a number code and
received specific oral hygiene instructions (brushing technique and
use of inter-proximal devices) and signed the informed consent
form at the beginning of the study. The patients also received the
study information sheet. Based on a random number table gener-
ated by a computer program, the research coordinator (Michel
R. Messora) assigned each patient to one of the following groups:
FIGURE 1 Flow chart of the clinical trial
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SANTANA ET AL.
control (MD + placebo) or test (MD + probiotic therapy). MD was
performed only on implants presenting PiM of individuals from the
control and test groups, who received either placebo capsules or
capsules containing 109 colony-forming units (CFUs) of B. lactis
HN019™ (HOWARU® Bifido, E. I. Dupont® de Nemoursand and
Company, Wilmington, DE), L. rhamnosus HN001™ (HOWARU®
Rhamnosus, E. I. Dupont® de Nemoursand and Company), and
L. paracasei Lpc-37® at baseline. All patients were instructed not to
take any other probiotic product during the study period. A maxil-
lofacial surgeon (Sandro I. Santana), who was blinded to the experi-
mental groups, performed the mechanical procedures for the
treatment of PiM. Another single examiner (Pedro H. F. Silva), who
was blinded to the experimental groups, assessed the peri-implant
clinical parameters at baseline (pre-intervention period) and at
12 and 24 weeks.
The same pharmacy prepared identical probiotic and placebo cap-
sules. Identical plastic bottles containing the probiotic/placebo capsules
were sent to the study coordinator (Michel R. Messora), who wrote the
number code of each patient on each bottle, according to the therapy
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SANTANA ET AL. 831

they were assigned to. The coded bottles were given to the examiner
(Pedro H. F. Silva), who distributed them to the patients and did not have
any access to information about the content of the capsules. In addition,
the patients were blinded to the content of the capsules and treatment
assignment during the study. The meaning of each number code was dis-
closed by the research coordinator only after the statistical analysis.
The patients received 14 capsules (placebo or probiotic) per
week. At the end of each week, the patients had to go to the Sul de
Minas Center for Oral Maxillofacial Surgery. They had to return the
empty capsules in order to receive new ones for the subsequent
week. During their visit, the patients answered a questionnaire about
their perception of any side effect during the treatment. Two research
assistants conducted these procedures and were in charge of monitor-
ing patient compliance with the treatment. The assistants were not
examiners or operators in the present study.
2.4 | Examiner calibration
Ten patients with at least one dental implant presenting BOP+ on at
least two sites were selected. Each patient was examined twice using
a plastic probe (University of North Carolina Colorvue probe,
Hu-Friedy, Chicago, IL) at a 48-h interval between the first and second
measurements. The calibration exercise was conducted according to
the methodology proposed by Araujo et al. (2003). The SEM and the
mean percentage error (MPE) for the continuous clinical parameters
(probing depth [PD]) were evaluated in individuals not participating in
the study. The intra-examiner SEM and MPE were, respectively,
0.23 mm and 9.09% for PD. For the categorical variables (modified
plaque index [mPI], modified sulcus bleeding index [mSBI], and BOP),
the mean level of agreement for the examiner was obtained, resulting
in a concordance greater than 85% (Kappa test).
2.5 | Clinical monitoring
Both mSBI and mPI were determined for each implant, according to
Mombelli et al. (1987). PD was determined using a University of North
Carolina Colorvue probe (Hu-Friedy). Three buccal and three lingual/
palatal reference points were used for each implant for measurement
of the mean PD (in millimetres), BOP, mSBI, and mPI. BOP was
assessed dichotomously (Ainamo & Bay, 1975). The height of
keratinized mucosa (in millimetres) in the buccal region of each implant
was also measured at baseline, using a University of North Carolina
Colorvue probe (Hu-Friedy). The measurements were made from the
mesiobuccal, buccal, and distobuccal regions of the free marginal peri-
implant mucosa to the mucogingival junction. All implants with PiM at
the baseline visit were evaluated. Each outcome was computed per
participant and then averaged across patients in both groups.
2.6 | Treatment of peri-implant mucositis and
maintenance care
Before the intervention, all patients received oral hygiene
instructions. MD was performed only on implants with PiM using
Teflon-coated scalers (Implacare™ II Scalers, Hu-Friedy, Chicago,
IL), rubber cup, and polishing paste. In the test group, the treatment

TABLE 1 Demographic characteristics of the sample at baseline according to experimental group

Experimental groups
Between-group
Variable Test (n = 18) Control (n = 18) comparisons
Individuals
Age, mean and (SD) 63.39 (12.06) 62.3 (9.50) NSa
Sex (female/male) 11/07 8/10 NSb
Implants
Number of implants, mean number and (SD) 4.38 (0.77) 4.36 (0.83) NSa
Number of implants with mucositis, mean number 2.44 (1.54) 2.52 (1.50) NSa
and (SD)
Oral hygiene: number of oral hygiene episodes/day, 2.77 (0.42) 2.5 (1.02) NSa
mean number and (SD)
Completely edentulous dental arch rehabilitated with implants
Upper (total number) 5 6 NSb
Lower (total number) 13 12
Denture
Fixed (Brånemark protocol) 18 18
HKM, mean and (SD) 2.09 (0.40) 2.57 (0.35) NSa

Abbreviations: HKM, height of keratinized mucosa; NS, non-significant.

a
Student's t test, p > .05.
b
Fisher's exact test, p > .05.
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832 SANTANA ET AL.

session was concluded with the topical application of carbo-
.0302
.0121
Mann–Whitney

xymethyl cellulose gel containing 109 CFUs of B. lactis HN019™,

NS
NS
Δ
Between-group comparison
T A B L E 2 Median, inter-quartile range (IQR), and confidence interval (CI) of probing depth (PD) and bleeding on probing (BOP), and changes in these parameters at 12 and 24 weeks when

L. rhamnosus HN001™, and L. paracasei Lpc-37®, around the

Median
p Value

implants. The gel was applied to the submucosal and supramucosal

.0163
.0090
test

areas. The patients were given capsules containing 109 CFUs of the
NS
NS
NS
NS

three probiotic microorganisms described earlier and were

difference

instructed to dissolve their contents in 20 ml of water, to rinse it

for 30–60 s, and to swallow it, doing that twice a day for 12 weeks.
Mean

14.54
12.56
0.28
0.35
0.12
1.51

The control group was treated with placebo gel and capsules. MD
was repeated at 12 postoperative weeks only in implants with PiM,

25.68 (29.59) [
32.81 to
14.74]

32.31 (25.70) [
41.69 to
23.04]

and the gel containing the probiotic or the placebo was also applied

0.29 (0.46) [
0.48 to
0.17]

0.33 (0.47) [
0.50 to
0.05]

to the test and control groups, respectively.

Delta (IQR) [95% CI]

2.7 | Immunological monitoring

Peri-implant crevicular fluid (PCF) was collected from all sites with BOP+
using absorbent paper strips (Periopaper®; Oralflow Inc., Amityville, NY)

Significant difference when compared with baseline (Friedman's test followed by Dunn's post hoc test for multiple comparisons, p < .05).
at baseline (pre-intervention period). These paper strips were grouped
into one microtube for immunological analysis, representing the data of
compared with baseline (Δ12–0/Δ24–0) in the test and control groups considering implants with peri-implant mucositis only

52.49 (11.74) [46.59 to 57.57]

26.81a (22.02) [18.73 to 37.87]
20.18 (16.75) [12.50 to 29.25]
the patient as the statistical unit. The same sites analysed at baseline
2.00 (0.80) [1.68 to 2.12]
1.58 (0.50) [1.37 to 1.73]
1.54 (0.81) [1.35 to 1.88]
were re-evaluated at both 12 and 24 weeks. During collection, absor-
Median (IQR) [95% CI]
bent paper strips contaminated with blood were discarded and a new
paper strip was inserted at that site for a new sample collection. Conven-
Control (n = 18)

tional enzyme immunoassays (ELISA) using commercially available kits

(DCTM Protein Assay; BioRad Laboratories, Inc., Berkeley, CA) were

a
performed to determine the amount of total protein in each sample.
Interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-17, IL-33, and tumour necrosis
factor-alpha (TNF-α) levels in PCF samples were determined using high

33.33 (22.84) [
46.79 to
30.04]

44.44 (12.48) [
48.45 to
40.43]
sensitivity kits (LXSAHM03—Techne Corporation, R&D Systems, Minne-

0.23 (0.54) [
0.46 to
0.10]

0.50 (0.75) [
1.28 to
0.29]
apolis, MN) and the multiplexing instrument (MAGPIX® analyser;
Luminex Corporation, Austin, TX). The concentrations of each cytokine

Delta (IQR) [95% CI]

were estimated from the standard curve using a five-parameter polyno-
mial equation with specific software (Xponent® software; Luminex Cor-
poration). The values of each cytokine were obtained from the
normalization of the data, considering the values of total protein.
2.8 | Outcome variables

50.23 (0.11) [45.93 to 55.20]

16.66a (22.84) [6.50 to 21.00]
12.48 (12.50) [3.80 to 12.81]
1.88 (0.97) [1.71 to 2.66]
1.50 (0.81) [1.37 to 2.43]
1.36a (0.42) [1.28 to 1.70]
Median (IQR) [95% CI]
The difference in mean changes of BOP (baseline—24 weeks)

Experimental groups
between test and control groups was used as the primary variable.
All other parameters (number of cases with peri-implant health, PD,

Test (n = 18)
BOP, mPI, mSBI, and mean levels of IL-1β, IL-6, IL-8, IL-10, IL-17,

Abbreviation: NS, non-significant.

IL-33, and TNF-α) were considered secondary outcomes.

12 weeks
24 weeks

12 weeks
24 weeks
Baseline

Baseline
2.9 | Statistical analysis

Period
The analyses were performed using GraphPad Prism (GraphPad Soft-

PD (mm)
Variable

BOP (%)
ware, Inc, version 6.0, San Diego, CA) and IBM SPSS Statistics (IBM
Corporation, version 23, Armonk, NY). The significance level was set
at 5% (p < .05). The Shapiro–Wilk test was used to check the normal

a
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SANTANA ET AL. 833

distribution of the data. Each outcome was computed per participant and
then averaged across patients in both groups. A posteriori power analysis
was performed considering the data obtained for the difference in mean
changes in BOP (baseline—24 weeks) between test and control groups.
The differences between the control and test groups for demo-
graphic data were assessed by Student's t test and Fisher's exact test.
The differences between the groups for the number of cases in which
peri-implant health was restored (patients without BOP) at 12 and
24 weeks were assessed by chi-square test.
Within-group differences (over time) in PD, BOP, mPI, and mSBI
were assessed by Friedman's test followed by Dunn's post hoc test
for multiple comparisons.
Between-group differences (in a given experimental period) in
PD, BOP, mean changes in BOP (baseline—12 weeks; baseline—
24 weeks), mPI, and mSBI were assessed by the Mann–Whitney test.
Within-group and between-group differences in the mean levels
of IL-1β, IL-6, IL-8, IL-10, IL-17, IL-33, and TNF-α were assessed by
Kruskal–Wallis followed by Dunn's post hoc test and Mann–Whitney
test, respectively.
3 | RESULTS
The flow chart of this study is shown in Figure 1. Thirty-six individuals
were included in the study. The study started in July 2018 and fin-
ished in November 2019. The demographic characteristics of the
experimental groups are shown in Table 1. All implants consisted of
neoporous surface and external hexagon system attached to mini
abutments (Neodent Implantes Osseointegráveis, Curitiba, Brazil). No
adverse effect was reported during and/or after the use of the cap-
sules containing probiotic or placebo. All patients showed complete
adherence to the protocol.
3.1 | Clinical monitoring
Tables 2, 3, and 4 present data only on implants with PiM at the base-
line visit. Table 2 shows PD and BOP, as well as the changes in these
parameters (at 12 and 24 weeks), compared with baseline measure-
ments (delta values—Δ) for the test and control groups. No significant
differences in PD and Δ were noted between the groups.
At 12 and 24 weeks, BOP was lower in the test group than in the
control group (p < .05). Changes in BOP (Δ) at 12 and 24 weeks were
higher in the test group than in the control group (p < .05). A post hoc
power analysis revealed the study had an 81% power to detect differ-
ences in changes in BOP (Δ) between the test and control groups at
24 weeks. This posteriori power analysis considered: n1—sample size
for control group = 18; n2—sample size for test group = 18; Δ jμ2

μ1j—absolute difference between two means (changes in BOP for test
and control groups at 24 weeks) = 12.08%; σ 1—variance of changes
in BOP for test group at 24 weeks = 6.01%; σ 2—variance of changes
in BOP for control group at 24 weeks = 17.02%; α = .05; β = .2.

T A B L E 3 Mean, SD, median, inter-quartile range (IQR), and confidence interval (CI) of modified plaque index at baseline, 12, and 24 weeks in
the test and control groups

mPI% scores
Mean (SD)
Median (IQR)
[95% CI]

Period Groups mPI-0 mPI-1 mPI–2 mPI-3

Baseline Test 17.59 (31.78) 11.54 (22.63) 31.36 (40.85) 39.51 (49.72)
0.0 (23.33) 0.0 (19.17) 10.0 (62.5) 0.0 (100.0)
[1.78 to 33.4] [0.28 to 22.80] [11.04 to 51.67] [14.78 to 64.23]
Control 11.42 (22.01) 7.94 (16.97) 38.39 (42.32) 4
0.0 (16.67) 0.0 (13.89) 25.0 (91.67) 2.25 (45.35)
[0.94 to 21.55] [0.0 to 15.89] [18.58 to 58.2] 22.5 (100.0)
[21.03 to 63.47]
12 weeks Test 36.79 (43.95) 1.66 (4.31) 38.77 (45.39) 22.78 (39.92)
0.0 (85.0) 0.0 (0.0) 16.67 (100.0) 0.0 (31.67)
[14.93 to 58.65] [
0.47 to 3.81] [16.19 to 61.34] [2.92 to 42.63]
Control 28.32 (32.45)a 7.87 (14.71) 33.41 (38.67) 30.4 (40.32)
10.42 (54.17) 0.0 (16.67) 23.61 (50.0) 2.78 (66.67)
[10.33 to 42.6] [0.55 to 15.18] [14.18 to 52.64] [10.35 to 50.45]
24 weeks Test 23.86 (37.83) 18.56 (31.65) 33.04 (40.48) 24.54 (40.44)
0.0 (48.33) 0.0 (40.0) 16.67 (69.45) 0.0 (48.61)
[4.40 to 43.3] [2.28 to 34.84] [12.23 to 53.85] [3.74 to 45.34]
Control 20.63 (26.41)a 21.09 (17.15) 36.73 (35.73) 21.55 (32.23)
0.0 (37.5) 22.22 (33.33) 29.17 (52.79) 8.33 (29.17)
[4.10 to 31.26] [12.28 to 29.91] [18.23 to 55.23] [4.98 to 38.12]

Abbreviation: mPI, modified plaque index.

a
Significant difference when compared with control group at baseline—mPI-0 (Friedman's test followed by Dunn's post hoc test, p < .05).
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834 SANTANA ET AL.

T A B L E 4 Mean, SD, median, inter-quartile range (IQR), and confidence interval (CI) of modified sulcus bleeding index at baseline, 12, and
24 weeks in the test and control groups

mSBI% scores
Mean (SD)
Median (IQR)
[95% CI]

Period Groups mSBI-0 mSBI-1 mSBI-2 mSBI-3

Baseline Test 48.89 (8.13) 26.08 (7.78) 23.18 (8.21) 1.85 (1.85)
50 (41.67) 15 (37.5) 2.78 (40.0) 0.0 (0.0)
[36.67 to 69.13] [9.66 to 42.5] [5.84 to 40.52] [
2.05 to 5.75]
Control 51.37 (7.17) 22.24 (6.22) 23.54 (6.65) 2.85 (1.74)
50.00 (37.50) 6.94 (40.83) 16.67 (40.63) 0.0 (0.0)
[36.35 to 66.40] [9.21 to 35.26] [9.60 to 37.48] [
0.80 to 6.50]
12 weeks Test 75.49 (8.15)a 18.80 (7.714) 3.86 (2.144) 1.85 (1.85)
4.45 (50.0) 0.0 (27.08) 0.0 (0.0) 0.0 (0.0)
[58.3 to 92.69] [2.521 to 35.07] [
0.66 to 8.38] [
2.05 to 5.75]
Control 67.98 (6.74) 11.99 (3.20) 18.27 (6.33)b 1.76 (1.874)
72.22 (41.67) 8.330 (16.67) 0.0 (37.5) 0.0 (4.0)
[53.82 to 82.14] [5.24 to 18.73] [4.96 to 31.58] [0.38 to 3.71]
24 weeks Test 80.82 (8.16)a 6.60 (5.85)c 10.78 (6.54) 1.80 (1.48)
100 (29.16) 0.0 (0.0) 0.0 (0.0) 0.0 (0.0)
[63.5 to 98.13] [
5.81 to 19.02] [
3.08 to 24.65] [
1.35 to 4.94]
Control 64.30 (7.12)d 16.08 (4.84)e 16.14 (6.28) 3.48 (1.50)
75 (53.76) 8.33 (26.39) [6.35 to 27.7] 0.0 (16.67) 0.0 (9.0)
[54.52 to 81.66] [2.46 to 19.95] [1.35 to 5.88]

Abbreviation: mSBI, modified sulcus bleeding index.

a
Significant difference when compared with test group at baseline—mSBI-0 (Friedman's test followed by Dunn's post hoc test, p < .05).
b
Significant difference when compared with test group at 12 weeks—mSBI-2 (Mann–Whitney test, p < .05).
c
Significant difference when compared with test group at baseline—mSBI-1 (Friedman's test followed by Dunn's post hoc test, p < .05).
d
Significant difference when compared with test group at 24 weeks—mSBI-0 (Mann–Whitney test, p < .05).
e
Significant difference when compared with test group at 24 weeks—mSBI-1 (Mann–Whitney test, p < .05).

mPI% and mSBI% for the test and control groups are displayed in than those at baseline (p < .05). At 24 weeks, only the test group had
Tables 3 and 4. No significant difference was observed between the lower levels of IL-1β, IL-6, IL-8, and TNF-α than those at base-
test and control groups for mPI%. mSBI%—score 0 was higher in the line (p < .05).
test group than in the control group at 24 weeks (p < .05). Also, mSBI
%—score 1 (24 weeks) and score 2 (12 weeks) were higher in the con-
trol group than in the test group (p < .05). 4 | DI SCU SSION

This double-blind, randomized, controlled trial clinically assessed

3.2 | Clinical significance of the treatments:
Complete resolution of inflammation
Regarding the number of cases in which peri-implant health was
restored (patients without BOP), 50% and 22.2% of the patients from
the test and control groups, respectively, did not show any sign of
BOP at 12 weeks (p = .08). At 24 weeks, 72.2% and 33.3% of the
patients from the test and control groups, respectively, did not show
any sign of BOP at 24 weeks (p = .0194).
3.3 | Immunological monitoring
IL-17, IL-1β, IL-6, IL-8, TNF-α, IL-33, and IL-10 levels are shown in
Table 5. Only the test group had higher levels of IL-10 at 12 weeks
the effects of the adjuvant use of multispecies probiotics on the
treatment of PiM. Results show that probiotic therapy provided
additional benefits at 12 and 24 weeks when compared with
conventional MD.
In the present study, the test group had significantly lower BOP
at 12 and 24 weeks than the control group. The decrease in BOP in
the test group at 12 and 24 weeks, when compared with baseline,
was approximately 38% and 44%, respectively. Immunomodulatory
and antimicrobial potential of probiotics could explain these results.
Previous studies have demonstrated a reduction in proinflammatory
cytokines (IL-6 and IL-8) and in the amount of Porphyromonas
gingivalis in the peri-implant sulcus of implants with mucositis treated
with probiotics (Flichy-Fernandez et al., 2015; Galofré et al., 2018). In
the present study, only the test group had lower levels of IL-1β, IL-6,
IL-8, and TNF-α at 24 weeks than those at baseline.
 1600051x, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13663 by Vrije Universiteit Amsterdam Library, Wiley Online Library on [17/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SANTANA ET AL. 835

T A B L E 5 Median, inter-quartile
Experimental groups
range (IQR), and confidence interval (CI)
of cytokines at 12 and 24 weeks in the Test (n = 18) Control (n = 18)
test and control groups Median (IQR) Median (IQR) Between-group comparison
Mann–Whitney test
Variable Period [95% CI] [95% CI] p Value
IL-17 Baseline 0.13 (0.3)a 0.07 (0.13)a NS
[0.121 to 0.322] [0.07 to 0.393]
12 weeks 0.0 (0.04)b 0.0 (0.03)b NS
[0.009 to 0.064] [
0.005 to 0.097]
24 weeks 0.0 (0.0)b 0.0 (0.02)b NS
[
0.003 to 0.016] [
0.004 to 0.053]
IL-1β Baseline 13.40 (25.67)a 4.51 (19.27)a NS
[14.40 to 38.16] [6.605 to 49.41]
12 weeks 3.61 (4.72)a,b 4.27 (6.22)a NS
[3.145 to 7.042] [4.252 to 8.760]
24 weeks 1.61 (1.26)b 2.30 (3.643)a,b NS
[1.425 to 4.079] [2.337 to 7.061]
IL-6 Baseline 1.91 (1.34)a 1.56 (0.89)a NS
[1.567 to 2.836] [0.974 to 2.971]
12 weeks 1.44 (1.49)a,b 1.24 (1.41)a,b NS
[0.9621 to 1.934] [1.125 to 2.225]
24 weeks 0.85 (0.44)b 1.02 (0.67)a,b NS
[0.6982 to 1.063] [0.7633 to 1.515]
IL-8 Baseline 153.2 (114.9)b 119.7 (106.43)a,b NS
[148.4 to 247.0] [28.30 to 383.1]
12 weeks 81.72 (100.99)a,c 85.95 (46.44)a,c NS
[64.32 to 109.1] [62.92 to 111.8]
24 weeks 66.26 (33.23)c 70.78 (140.12)a,c NS
[57.11 to 75.93] [66.99 to 182.3]
IL-33 Baseline 0.24 (0.12)a 0.22 (0.08)a NS
[0.208 to 0.300] [0.201 to 0.280]
12 weeks 0.19 (0.16)a 0.22 (0.09)a NS
[0.137 to 0.254] [0.171 to 0.298]
24 weeks 0.17 (0.08)a 0.19 (0.11)a NS
[0.138 to 0.196] [0.157 to 0.259]
IL-10 Baseline 0.44 (0.18)a 0.40 (0.25)a NS
[0.341 to 0.504] [0.321 to 0.493]
12 weeks 0.53 (0.39)b 0.52 (0.22)a,b NS
[0.4953 to 0.7563] [0.4202 to 0.6548]
24 weeks 0.39 (0.18)a,b 0.40 (0.17)a NS
[0.379 to 0.553] [0.328 to 0.471]
TNF-α Baseline 0.28 (0.16)a 0.24 (0.24)a NS
[0.235 to 0.370] [0.222 to 0.365]
12 weeks 0.24 (0.19)a,b 0.27 (0.16)a,b NS
[0.175 to 0.307] [0.206 to 0.342]
24 weeks 0.16 (0.04)b 0.25 (0.11)a,b NS
[0.139 to 0.177] [0.180 to 0.346]

Note: Different letters indicate statistical differences between different times (Kruskal–Wallis test
followed by Dunn's post hoc test for multiple comparisons, p < .05).
Abbreviation: NS, non-significant.

To date, only three (Flichy-Fernandez et al., 2015; et al., 2019) have shown an additional positive effect of probiotics
Galofré et al., 2018; Alqahtani et al., 2019) of six studies (Flichy- in the treatment of PiM. Several factors could explain the contra-
Fernandez et al., 2015; Hallström et al., 2016; Mongardini dictory results. An important aspect is the bacterial strain used. The
et al., 2017; Galofré et al., 2018; Alqahtani et al., 2019; Peña results obtained with the use of probiotic microorganisms should

836
not be generalized, because they depend on the genus and on the
bacterial strain used, among other factors. Additional benefits were
observed in the treatment of PiM with the adjuvant use of Lactoba-
cillus reuteri (Flichy-Fernandez et al., 2015; Galofré et al., 2018;
Alqahtani et al., 2019). However, the adjuvant use of Lactobacillus
plantarum and Lactobacillus brevis (Mongardini et al., 2017) was
ineffective.
So far, studies on the effects of probiotics on PiM have used only
microorganisms of the genus Lactobacillus. The present study is the
first one to demonstrate the potential of the probiotic bacterium of
the genus Bifidobacterium for the treatment of PiM. In this study, sig-
nificant differences in BOP were still observed in the test and control
groups at 6 months. Alqahtani et al. (2019) used only microorganisms
of the genus Lactobacillus in the treatment of PiM. The results showed
additional benefits of probiotic therapy when compared with MD
(reduction of BOP) only at 3 months. These benefits were no longer
present at 6 months. Previous studies conducted by our research
group have already shown that B. lactis HN019 can modulate the oral
microbiota and host immune response, contributing to the prevention
and treatment of periodontal diseases (Oliveira et al., 2017; Ricoldi
et al., 2017; Invernici et al., 2018). In the present study, probiotic ther-
apy was administered topically (directly on the dental implants and
peri-implant mucosa), and also ingested by patients. Thus, a combina-
tion of direct (oral site) and indirect (intestinal environment) effects
might have contributed to the findings. Kobayashi et al. (2017)
evidenced that probiotic administration undertaken via gavage pro-
moted beta-defensins synthesis at distant sites, such as in the gingiva
of rats. Still, regarding the systemic action of probiotics, Gatej et al.
(2018) demonstrated that animals previously treated with probiotics
through gavage or oral inoculation exhibited a reduction in serum
inflammatory markers.
The additional benefits of probiotic therapy persisted in the pre-
sent study for 90 days after its discontinuation. This could be due to
the fact that some probiotic strains incorporate into the oral biofilm,
even if temporarily. In individuals with periodontitis treated with
B. lactis HN019, copies of the genome of this microorganism were
found in the oral biofilm 60 days after the therapy had been discon-
tinued (Invernici et al., 2018). Meurman et al. (1994), Iniesta et al.
(2012), and Tekce et al. (2015) also noted the persistence of bacteria
of the genus Lactobacillus in the oral cavity at 2, 8, and 9 weeks,
respectively, after discontinuation of probiotic therapy.
In the present study, both groups showed similar mPI and quite
different BOP values. Probiotic therapy, even when administered for
a short time, seems to provide more resilience to the oral microbiome
to risk factors for oral tissue inflammation, such as dental plaque
build-up (Rosier et al., 2018). Invernici et al. (2020) demonstrated that
probiotic bacteria can change the expression of markers involved in
the regulation of the immunocompetence of the epithelial barrier. The
results of the present study suggest a possible effect of probiotic ther-
apy on the delayed onset of peri-implant inflammation. At 24 weeks,
only the test group had lower levels of IL-1β, IL-6, IL-8, and TNF-α
than those at baseline. J. K. Lee et al. (2015) showed that L. brevis loz-
enges significantly delayed the onset of gingival inflammation in
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SANTANA ET AL.
healthy individuals who had abstained from oral hygiene. Kuru et al.
(2017) demonstrated that patients with experimental gingivitis treated
with B. lactis DN-173010 for 30 days before the onset of gingivitis
had lower IL-1β levels in the gingival crevicular fluid when compared
with those who were not treated prophylactically with this probiotic
strain.
In the present study, 33.3% of the patients from the control
group did not show any sign of BOP at 24 weeks. The complete reso-
lution of PiM was defined as the absence of BOP around a dental
implant after treatment of mucositis (Sanz & Chapple, 2012). Even
though this finding was presented by pre-clinical trials (Ericsson
et al., 1995) and in human studies (Pontoriero et al., 1994; Salvi
et al., 2012), thus defining PiM as a reversible lesion, clinical trials
have demonstrated that it is not an easy task to have this outcome in
the long run (Heitz-Mayfield et al., 2011; Schwarz et al., 2015;
Mongardini et al., 2017; Peña et al., 2019). The use of probiotics as
adjuvant therapy to MD in the present study increased the complete
resolution of PiM by over 70%.
In the present study, two bleeding parameters were assessed at
the same sites. mSBI was used to evaluate through scores the mar-
ginal bleeding of peri-implant tissue, as described by Mombelli et al.
(1987). On the other hand, BOP was used to evaluate dichotomously
the bleeding of peri-implant sulcus, assessing its probing depth. In the
present study, the evaluation of both parameters demonstrated less
bleeding in the test group when compared with the control group.
Pontoriero et al. (1994) also demonstrated concordance between both
evaluation methods, indicating greater peri-implant mucosal inflamma-
tion (greater mSBI scores concomitantly with greater BOP) after bio-
film accumulation.
In this study, MD was performed only on implants with PiM using
Teflon-coated scalers, rubber cup, and polishing paste. A systematic
review demonstrated the percentage of BOP reduction can vary
among groups that utilized non-surgical therapies (Barootchi
et al., 2020). For the mechanical therapy with curettes alone, an aver-
age reduction of 26.21% (95% CI [15.69 to 36.73]) in BOP was
observed, while a mean reduction of 13.3% (95% CI [
0.24 to 26.85])
was estimated when curettes were used together with ultrasonic
scalers (Barootchi et al., 2020). Nevertheless, there is no evidence
demonstrating superiority of a mechanical method over others in the
treatment of PiM (Jepsen et al., 2015; Barootchi et al., 2020). This
confirms that, regardless of the selected treatment, an effective
plaque control is the primary factor for restoring peri-implant health.
It is also important to consider the heterogeneity among studies when
drawing conclusions about which treatment for PiM is the most effec-
tive and also to what extent treatment can restore peri-implant health
(Barootchi et al., 2020).
In this study, several factors that could interfere with the out-
comes were controlled. The capsules containing probiotics were mon-
itored during the study to maintain their viability and the amount of
CFUs. The modes of administration of the probiotics (mouth rinses
and topical applications) were planned to maximize the contact of
microorganisms with peri-implant tissues. Prior to the probiotic ther-
apy, careful MD was carried out in the test and control groups for

SANTANA ET AL.
maximum biofilm removal. There was no significant difference in
demographic variables at baseline between the test and control
groups, especially for height of keratinized mucosa (means of 2.09
and 2.57 for the test and control groups, respectively).
Only implants in completely edentulous arches were included
in the present study. A systematic review (de Waal et al., 2013)
demonstrated that no conclusions could be drawn as to the preva-
lence of PiM and peri-implantitis among fully edentulous partici-
pants (FEPs) and partially edentulous participants (PEPs). However,
different ecological conditions involving the oral microbiome can
be found in FEPs and PEPs. Their results also indicate that FEPs
generally show higher plaque levels than PEPs. It might be hypoth-
esized that FEPs are less accustomed to maintaining proper oral
hygiene levels because they did not (need to) do so before receiv-
ing oral implants. A second explanation could be that plaque around
implants supporting overdentures is more persistent than plaque
around implants supporting single crowns and partial bridges,
because it is less accessible for natural cleaning by tongue, lip,
cheek, and saliva (de Waal et al., 2013).
The present study is the first one to demonstrate the potential
of a cocktail of microorganisms, combining bacteria of the genera
Bifidobacterium and Lactobacillus for the treatment of PiM. A limita-
tion of the present study was the short assessment period. The
follow-up of the participants for a longer time would be important
to check whether the additional effects of probiotic therapy on MD
are maintained over time. Microbiological analyses would also be
important to elucidate the mechanisms of action of the probiotic
therapy.
5 | C O N CL U S I O N
The use of B. lactis HN019™, L. rhamnosus HN001™, and L. paracasei
Lpc-37® (administered locally and systemically) as an adjunct to
repeated MD promotes additional clinical and immunological benefits
to the treatment of PiM in edentulous patients. The complete resolu-
tion of inflammation was not achieved in all cases.
AUTHOR CONTRIBUTIONS
Sandro I. Santana performed the mechanical procedures for the
treatment of peri-implant mucositis. Pedro H. F. Silva assessed the
peri-implant clinical parameters at baseline (pre-intervention
period) and at 12 and 24 weeks. Sérgio L. Salvador supervised the
preparation of the probiotic capsules and performed microbiologi-
cal analyses to ensure the viability of microorganisms in the pre-
pared products. Renato C. V. Casarin performed the immunological
analysis. Flávia A. C. Furlaneto contributed to the statistical analy-
sis of the data obtained and to the writing of the paper. Michel
R. Messora performed the statistical analysis of all data collected
and wrote the paper.
FUND ING INFORMATION
This study was funded by the authors and their institutions.
1600051x, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13663 by Vrije Universiteit Amsterdam Library, Wiley Online Library on [17/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
837
CONFLIC T OF INT ER E ST
The authors report no conflicts of interest related to this study.
DATA AVAILABILITY STAT EMEN T
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ET HICS S TAT E MENT
The authors have stated explicitly that there are no conflict of inter-
ests in connection with this article.
OR CID
Pedro H. F. Silva https://orcid.org/0000-0002-7583-7046
Renato C. V. Casarin https://orcid.org/0000-0003-1743-5855
RE FE RE NCE S
Ainamo, J., & Bay, I. (1975). Problems and proposals for recording gingivitis
and plaque. International Dental Journal, 25(4), 229–235.
Albaker, A. M., ArRejaie, A. S., Alrabiah, M., & Abduljabbar, T. (2018). Effect
of photodynamic and laser therapy in the treatment of peri-implant
mucositis: A systematic review. Photodiagnosis and Photodynamic Ther-
apy, 21, 147–152. https://doi.org/10.1016/j.pdpdt.2017.11.011
Alqahtani, F., Alqahtani, M., Shafqat, S. S., Akram, Z., Al-Kheraif, A. A., &
Javed, F. (2019). Efficacy of mechanical debridement with adjunctive
probiotic therapy in the treatment of peri-implant mucositis in
cigarette-smokers and never-smokers. Clinical Implant Dentistry and
Related Research, 21(4), 734–740. https://doi.org/10.1111/cid.
12795
Araujo, M. W., Hovey, K. M., Benedek, J. R., Grossi, S. G., Dorn, J.,
Wactawski-Wende, J., Genco, R. J., & Trevisan, M. (2003). Reproduc-
ibility of probing depth measurement using a constant-force electronic
probe: Analysis of inter- and intraexaminer variability. Journal of Peri-
odontology, 74, 1736–1740.
Barootchi, S., Ravidà, A., Tavelli, L., & Wang, H. L. (2020). Nonsurgical
treatment for peri-implant mucositis: A systematic review and meta-
analysis. The International Journal of Oral Implantology, 13(2), 123–139.
Berglundh, T., Armitage, G., Araujo, M. G., Avila-Ortiz, G., Blanco, J.,
Camargo, P. M., Chen, S., Cochran, D., Derks, J., Figuero, E.,
Hämmerle, C. H. F., Heitz-Mayfield, L. J. A., Huynh-Ba, G., Iacono, V.,
Koo, K. T., Lambert, F., McCauley, L., Quirynen, M., Renvert, S., …
Zitzmann, N. (2018). Peri-implant diseases and conditions: Consensus
report of workgroup 4 of the 2017 World Workshop on the Classifica-
tion of Periodontal and Peri-Implant Diseases and Conditions. Journal
of Periodontology, 89(Suppl. 1), S313–S318. https://doi.org/10.1002/
JPER.17-0739
Ciancio, S. G., Lauciello, F., Shibly, O., Vitello, M., & Mather, M. (1995). The
effect of an antiseptic mouthrinse on implant maintenance: Plaque
and peri-implant gingival tissues. Journal of Periodontology, 66(11),
962–965. https://doi.org/10.1902/jop.1995.66.11.962
Derks, J., & Tomasi, C. (2015). Peri-implant health and disease. A system-
atic review of current epidemiology. Journal of Clinical Periodontology,
42(Suppl 16), S158-71. https://doi.org/10.1111/jcpe.12334
de Waal, Y. C., van Winkelhoff, A. J., Meijer, H. J., Raghoebar, G. M., &
Winkel, E. G. (2013). Differences in peri-implant conditions between
fully and partially edentulous subjects: A systematic review. Journal of
Clinical Periodontology, 40(3), 266–286. https://doi.org/10.1111/jcpe.
12013
Ericsson, I., Persson, L. G., Berglundh, T., Marinello, C. P., Lindhe, J., &
Klinge, B. (1995). Different types of inflammatory reactions in peri-
implant soft tissues. Journal of Clinical Periodontology, 22(3), 255–261.
https://doi.org/10.1111/j.1600-051x.1995.tb00143.x

838
Flichy-Fernandez, A. J., Ata-Ali, J., Alegre-Domingo, T., Candel-Mart, E.,
Ata-Ali, F., Palacio, J. R., & Penarrocha-Diago, M. (2015). The effect of
orally administered probiotic Lactobacillus reuteri-containing tablets in
peri-implant mucositis: A double-blind randomized controlled trial.
Journal of Periodontal Research, 50(6), 775–785. https://doi.org/10.
1111/jre.12264
Galofré, M., Palao, D., Vicario, M., Nart, J., & Violant, D. (2018). Clinical
and microbiological evaluation of the effect of Lactobacillus reuteri in
the treatment of mucositis and peri-implantitis: A triple-blind random-
ized clinical trial. Journal of Periodontal Research, 53(3), 378–390.
https://doi.org/10.1111/jre.12523
Gatej, S. M., Marino, V., Bright, R., Fitzsimmons, T. R., Gully, N., Zilm, P.,
Gibson, R. J., Edwards, S., & Bartold, P. M. (2018). Probiotic Lactobacil-
lus rhamnosus GG prevents alveolar bone loss in a mouse model of
experimental periodontitis. Journal of Clinical Periodontology, 45, 204–
212. https://doi.org/10.1111/jcpe.12838
Gruner, D., Paris, S., & Schwendicke, F. (2016). Probiotics for managing
caries and periodontitis: Systematic review and meta-analysis. Journal
of Dentistry, 48, 16–25. https://doi.org/10.1016/j.jdent.2016.03.002
Hallström, H., Lindgren, S., Widén, C., Renvert, S., & Twetman, S. (2016).
Probiotic supplements and debridement of peri-implant mucositis: A
randomized controlled trial. Acta Odontologica Scandinavica, 74(1), 60–
66. https://doi.org/10.3109/00016357.2015.1040065
Hallström, H., Lindgren, S., Yucel-Lindberg, T., Dahlen, G., Renvert, S., &
Twetman, S. (2013). Effect of probiotic lozenges on inflammatory reac-
tions and oral biofilm during experimental gingivitis. Acta Odontologica
Scandinavica, 71(3–4), 828–833. https://doi.org/10.3109/00016357.
2012.734406
Hallström, H., Persson, G. R., Lindgren, S., Olofsson, M., & Renvert, S.
(2012). Systemic antibiotics and debridement of peri-implant
mucositis. A randomized clinical trial. Journal of Clinical Periodontology,
39, 574–581. https://doi.org/10.1111/j.1600-051X.2012.01884.x
Harini, P. M., & Anegundi, R. T. (2010). Efficacy of a probiotic and chlor-
hexidine mouth rinses: A short-term clinical study. Journal of the Indian
Society of Pedodontics and Preventive Dentistry, 28(3), 179–182.
https://doi.org/10.4103/0970-4388.73799
Heitz-Mayfield, L. J., & Lang, N. P. (2004). Antimicrobial treatment of peri-
implant diseases. The International Journal of Oral & Maxillofacial
Implants, 19(Suppl), 128–139.
Heitz-Mayfield, L. J., Salvi, G. E., Botticelli, D., Mombelli, A., Faddy, M.,
Lang, N. P., & Implant Complication Research Group. (2011). Anti-
infective treatment of peri-implant mucositis: A randomised controlled
clinical trial. Clinical Oral Implants Research, 22(3), 237–241. https://
doi.org/10.1111/j.1600-0501.2010.02078.x
Hill, C., Guarner, F., Reid, G., Gibson, G. R., Merenstein, D. J., Pot, B.,
Morelli, L., Canani, R. B., Flint, H. J., Salminen, S., Calder, P. C., &
Sanders, M. E. (2014). The International Scientific Association for Pro-
biotics and Prebiotics consensus statement on the scope and appropriate
use of the term probiotic. Nature Reviews. Gastroenterology & Hepatology,
11(8), 506–514. https://doi.org/10.1038/nrgastro.2014.66
Iniesta, M., Herrera, D., Montero, E., Zurbriggen, M., Matos, A. R.,
Marin, M. J., et al. (2012). Probiotic effects of orally administered Lac-
tobacillus reuteri-containing tablets on the subgingival and salivary
microbiota in patients with gingivitis. A randomized clinical trial. Jour-
nal of Clinical Periodontology, 39(8), 736–744. https://doi.org/10.
1111/j.1600-051X.2012.01914.x
Invernici, M. M., Furlaneto, F. A. C., Salvador, S. L., Ouwehand, A. C.,
Salminen, S., Mantziari, A., Vinderola, G., Ervolino, E., Santana, S. I.,
Silva, P. H. F., & Messora, M. R. (2020). Bifidobacterium animalis subsp
lactis HN019 presents antimicrobial potential against per-
iodontopathogens and modulates the immunological response of oral
mucosa in periodontitis patients. PLoS One, 15(9), e0238425. https://
doi.org/10.1371/journal.pone.0238425
Invernici, M. M., Salvador, S. L., Silva, P. H. F., Soares, M. S. M., Casarin, R.,
Palioto, D. B., Souza, S. L. S., Taba, M., Jr., Novaes, A. B., Jr.,
1600051x, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13663 by Vrije Universiteit Amsterdam Library, Wiley Online Library on [17/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SANTANA ET AL.
Furlaneto, F. A. C., & Messora, M. R. (2018). Effects of Bifidobacterium
probiotic on the treatment of chronic periodontitis: A randomized clin-
ical trial. Journal of Clinical Periodontology, 45(10), 1198–1210. https://
doi.org/10.1111/jcpe.12995
Jepsen, S., Berglundh, T., Genco, R., Aass, A. M., Demirel, K., Derks, J.,
Figuero, E., Giovannoli, J. L., Goldstein, M., Lambert, F., Ortiz-
Vigon, A., Polyzois, I., Salvi, G. E., Schwarz, F., Serino, G., Tomasi, C., &
Zitzmann, N. U. (2015). Primary prevention of peri-implantitis: Manag-
ing peri-implant mucositis. Journal of Clinical Periodontology, 42(Suppl.
16), S152–S157. https://doi.org/10.1111/jcpe.12369
Ji, Y.-J., Tang, Z.-H., Wang, R., Cao, J., Cao, C.-F., & Jin, L.-J. (2014). Effect
of glycine powder air-polishing as an adjunct in the treatment of peri-
implant mucositis: A pilot clinical trial. Clinical Oral Implants Research,
25(6), 683–689. https://doi.org/10.1111/clr.12123
Kobayashi, R., Kobayashi, T., Sakai, F., Hosoya, T., Yamamoto, M., &
Kurita-Ochiai, T. (2017). Oral administration of Lactobacillus gasseri
SBT2055 is effective in preventing Porphyromonas gingivalis-
accelerated periodontal disease. Scientific Reports, 7(1), 545. https://
doi.org/10.1038/s41598-017-00623-9
Krasse, P., Carlsson, B., Dahl, C., Paulsson, A., Nilsson, A., &
Sinkiewicz, G. (2006). Decreased gum bleeding and reduced gingivi-
tis by the probiotic Lactobacillus reuteri. Swedish Dental Journal,
30(2), 55–60.
Kuru, B. E., Laleman, I., Yalnızoglu, T., Kuru, L., & Teughels, W. (2017). The
influence of a Bifidobacterium animalis probiotic on gingival health: A
randomized controlled clinical trial. Journal of Periodontology, 88(11),
1115–1123. https://doi.org/10.1902/jop.2017.170213
Lang, N. P., Bosshardt, D. D., & Lulic, M. (2011). Do mucositis lesions
around implants differ from gingivitis lesions around teeth? Journal of
Clinical Periodontology, 38(Suppl. 11), 182–187. https://doi.org/10.
1111/j.1600-051X.2010.01667.x
Lee, C.-T., Huang, Y.-W., Zhu, L., & Weltman, R. (2017). Prevalences of
peri-implantitis and peri-implant mucositis: Systematic review and
meta-analysis. Journal of Dentistry, 62, 1–12. https://doi.org/10.1016/
j.jdent.2017.04.011
Lee, J. K., Kim, S. J., Ko, S. H., Ouwehand, A. C., & Ma, D. S. (2015). Modu-
lation of the host response by probiotic Lactobacillus brevis CD2 in
experimental gingivitis. Oral Diseases, 21(6), 705–712. https://doi.org/
10.1111/odi.12332
Lindhe, J., Meyle, J., & Group D of European Workshop on Periodontol-
ogy. (2008). Peri-implant diseases: Consensus Report of the Sixth
European Workshop on Periodontology. Journal of Clinical Periodontol-
ogy, 35(8 Suppl), 282–285. https://doi.org/10.1111/j.1600-051X.
2008.01283.x
Liu, S., Li, M., & Yu, M. (2020). Does chlorhexidine improve outcomes in
non-surgical management of peri-implant mucositis or peri-
implantitis?: A systematic review and meta-analysis. Medicina Oral,
Patología Oral y Cirugía Bucal, 25(5), e608–e615. https://doi.org/10.
4317/medoral.23633
Martin-Cabezas, R., Davideau, J., Tenenbaum, H., & Huck, O. (2016). Clini-
cal efficacy of probiotics as an adjunctive therapy to non-surgical peri-
odontal treatment of chronic periodontitis: A systematic review and
meta-analysis. Journal of Clinical Periodontology, 43(6), 520–530.
https://doi.org/10.1111/jcpe.12545
Maximo, M. B., de Mendonca, A. C., Renata, S. V., Figueiredo, L. C.,
Feres, M., & Duarte, P. M. (2009). Short-term clinical and microbiologi-
cal evaluations of peri-implant diseases before and after mechanical
anti-infective therapies. Clinical Oral Implants Research, 20(1), 99–108.
https://doi.org/10.1111/j.1600-0501.2008.01618.x
Meurman, J. H., Antila, H., & Salminen, S. (1994). Recovery of Lactobacillus
strain GG (ATCC 53103) from saliva of healthy volunteers after con-
sumption of yoghurt prepared with the bacterium. Microbial Ecology in
Health and Disease, 7(6), 295–298.
Mombelli, A., Van Oosten, M. A. C., Schiirch, E., & Lang, N. P. (1987). The
microbiota associated with successful or failing osseointegrated

SANTANA ET AL.
titanium implants. Oral Microbiology and Immunology, 2(4), 145–151.
https://doi.org/10.1111/j.1399-302x.1987.tb00298.x
Mongardini, C., Pilloni, A., Farina, R., Di Tanna, G., & Zeza, B. (2017).
Adjunctive efficacy of probiotics in the treatment of experimental
peri-implant mucositis with mechanical and photodynamic therapy: A
randomized, cross-over clinical trial. Journal of Clinical Periodontology,
44(4), 410–417. https://doi.org/10.1111/jcpe.12689
Nadkerny, P. V., Ravishankar, P. L., Pramod, V., Agarwal, L. A., &
Bhandari, S. (2015). A comparative evaluation of the efficacy of probi-
otic and chlorhexidine mouthrinses on clinical inflammatory parame-
ters of gingivitis: A randomized controlled clinical study. Journal of
Indian Society of Periodontology, 19(6), 633–639. https://doi.org/10.
4103/0972-124X.168491
Oliveira, L. F. F., Salvador, S. L., Silva, P. H. F., Furlaneto, F. A. C.,
Figueiredo, L., Casarin, R., Ervolino, E., Palioto, D. B., Souza, S. L. S.,
Taba, M., Jr., Novaes, A. B., Jr., & Messora, M. R. (2017). Benefits of
Bifidobacterium animalis subsp. lactis probiotic in experimental peri-
odontitis. Journal of Periodontology, 88(2), 197–208. https://doi.org/
10.1902/jop.2016.160217
Peña, M., Barallat, L., Vilarrasa, J., Vicario, M., Violant, D., & Nart, J. (2019).
Evaluation of the effect of probiotics in the treatment of peri-implant
mucositis: A triple-blind randomized clinical trial. Clinical Oral Investiga-
tions, 23(4), 1673–1683. https://doi.org/10.1007/s00784-018-2578-8
Pontoriero, R., Tonelli, M. P., Carnevale, G., Mombelli, A., Nyman, S. R., &
Lang, N. P. (1994). Experimentally induced peri-implant mucositis. A
clinical study in humans. Clinical Oral Implants Research, 5(4), 254–259.
https://doi.org/10.1034/j.1600-0501.1994.050409.x
Porras, R., Anderson, G. B., Caffesse, R., Narendran, S., & Trejo, P. M.
(2002). Clinical response to 2 different therapeutic regimens to treat
peri-implant mucositis. Journal of Periodontology, 73(10), 1118–1125.
https://doi.org/10.1902/jop.2002.73.10.1118
Ramanauskaite, A., Fretwurst, T., & Schwarz, F. (2021). Efficacy of alterna-
tive or adjunctive measures to conventional non-surgical and surgical
treatment of peri-implant mucositis and peri-implantitis: A systematic
review and meta-analysis. International Journal of Implant Dentistry, 7,
112. https://doi.org/10.1186/s40729-021-00388-x
Renvert, S., Roos-Jansaker, A. M., & Claffey, N. (2008). Non-surgical treat-
ment of peri-implant mucositis and peri-implantitis: A literature
review. Journal of Clinical Periodontology, 35(8 Suppl), 305–315.
https://doi.org/10.1111/j.1600-051X.2008.01276.x
Ricoldi, M. S. T., Furlaneto, F. A. C., Oliveira, L. F. F., Teixeira, G. C.,
Pischiotini, J. P., Moreira, A. L. G., Ervolino, E., de Oliveira, M. N.,
Bogsan, C. S. B., Salvador, S. L., & Messora, M. R. (2017). Effects of the
probiotic Bifidobacterium animalis subsp. lactis on the non-surgical
treatment of periodontitis. A histomorphometric, microtomographic
and immunohistochemical study in rats. PLoS One, 12(6), e0179946.
https://doi.org/10.1371/journal.pone.0179946
Rosier, B. T., Marsh, P. D., & Mira, A. (2018). Resilience of the oral microbiota
in health: Mechanisms that prevent dysbiosis. Journal of Dental Research,
97(4), 371–380. https://doi.org/10.1177/0022034517742139
1600051x, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13663 by Vrije Universiteit Amsterdam Library, Wiley Online Library on [17/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
839
Salvi, G. E., Aglietta, M., Eick, S., Sculean, A., & Ramseier, C. A. (2012).
Reversibility of experimental peri-implant mucositis compared with
experimental gingivitis in humans. Clinical Oral Implants Research,
23(2), 182–190. https://doi.org/10.1111/j.1600-0501.2011.
02220.x
Sanz, M., & Chapple, I. L. (2012). Clinical research on peri-implant diseases:
Consensus report of Working Group 4. Journal of Clinical Periodontol-
ogy, 39(Suppl. 12), 202–206. DOI; 10.1111/j.1600-051X.2011.
01837.x
Schwarz, F., Becker, K., & Sager, M. (2015). Efficacy of professionally
administered plaque removal with or without adjunctive measures for
the treatment of peri-implant mucositis. A systematic review and
meta-analysis. Journal of Clinical Periodontology, 42(Suppl. 16), S202–
S213. https://doi.org/10.1111/jcpe.12349
Staab, B., Eick, S., Knöfler, G., & Jentsch, H. (2009). The influence of a pro-
biotic milk drink on the development of gingivitis: A pilot study. Journal
of Clinical Periodontology, 36(10), 850–856. https://doi.org/10.1111/j.
1600-051X.2009.01459.x
Tekce, M., Ince, G., Gursoy, H., Dirikan, I. S., Cakar, G., Kadir, T., &
Yılmaz, S. (2015). Clinical and microbiological effects of probiotic loz-
enges in the treatment of chronic periodontitis: A 1-year follow-up
study. Journal of Clinical Periodontology, 42(4), 363–372. https://doi.
org/10.1111/jcpe.12387
Thone-Muhling, M., Swierkot, K., Nonnenmacher, C., Mutters, R., Flores-
de-Jacoby, L., & Mengel, R. (2010). Comparison of two full-mouth
approaches in the treatment of peri-implant mucositis: A pilot study.
Clinical Oral Implants Research, 21(5), 504–512. https://doi.org/10.
1111/j.1600-0501.2009.01861.x
Twetman, S., Derawi, B., Keller, M., Ekstrand, K., Yucel-Lindberg, T., &
Stecksen-Blicks, C. (2009). Short–term effect of chewing gums
containing probiotic Lactobacillus reuteri on the levels of inflamma-
tory mediators in gingival crevicular fluid. Acta Odontologica
Scandinavica, 67(1), 19–24. https://doi.org/10.1080/000163
50802516170
Yu, X. L., Chan, Y., Zhuang, L. F., Lai, H. C., Lang, N. P., Lacap-Bugler, D. C.,
Leung, W. K., & Watt, R. M. (2016). Distributions of Synergistetes in
clinically-healthy and diseased periodontal and peri-implant niches.
Microbial Pathogenesis, 94, 90–103. https://doi.org/10.1016/j.
micpath.2015.11.029
How to cite this article: Santana, S. I., Silva, P. H. F., Salvador,
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