IMPLANT DENTISTRY / VOLUME 24, NUMBER 1 2015
Treatment of Periimplant Mucositis:
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13
A Systematic Review of Randomized
Controlled Trials
Javier Ata-Ali, DDS, MS, MPH, PhD,* Fadi Ata-Ali, DDS, MS,† and Pablo Galindo-Moreno, DDS, PhD‡
n the same way as in the case of
I peri-implantitis,1 the definitions of
periimplant mucositis vary in the
literature, and no clear criteria have
been established regarding the diag-
nosis and treatment of this disorder.
The Sixth European Workshop in
Periodontology2 held in 2008 in
Göteborg (Sweden) defined periim-
plant mucositis as inflammation of
the periimplant mucosa, without signs
of supporting bone loss. Later, the
Seventh European Workshop in Peri-
odontology3 held in Segovia (Spain)
established the presence of bleeding
on probing (BOP) as the key parameter
for diagnosing periimplant mucositis.
According to the latest definition of
the American Academy of Periodontol-
ogy,4 periimplant mucositis is a disease
in which the presence of inflammation
is confined to the soft tissues surround-
ing a dental implant, with no signs of
loss of supporting bone after initial
bone remodeling during healing.
Experimental studies in humans
have shown that the accumulation of
bacterial plaque during a period of 3
weeks exhibits a similar effect in both
*Master in Oral Surgery and Medicine, Master in Oral Surgery
and Implantology, Public Dental Health Service, Arnau de
Vilanova Hospital, Valencia University Medical and Dental
School, Valencia, Spain.
†Valencia University Medical and Dental School, Valencia, Spain.
‡Department of Oral Surgery and Implant Dentistry, School of
Dentistry, University of Granada, Granada, Spain.
Reprint requests and correspondence to: Javier Ata-Ali,
DDS, MS, MPH, PhD, Public Dental Health Service,
Arnau de Vilanova Hospital, San Clemente Street 12,
46015 Valencia, Spain, Phone: +0034963868501, Fax:
00963868197, E-mail: javiataali@hotmail.com
ISSN 1056-6163/15/02401-013
Implant Dentistry
Volume 24
Number 1
Copyright © 2014 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0000000000000190
Objective: To determine the most
effective treatment for periimplant
mucositis in patients with dental im-
plants compared with a control group.
Materials and Methods: A
PubMed (MEDLINE) literature
search was made of articles published
up until October 2013. Randomized
controlled trials (RCTs) were strati-
fied according to their level of quality
using the Jadad scale and levels of
evidence (University of Oxford).
Results: The combinations of
search terms resulted in a list of 371
titles. Of these, 114 references were
finally reviewed. Finally, 7 RCTs
fulfilled the inclusion criteria and
were thus selected for inclusion in
the systematic review. Chlorhexidine,
the administration of azithromycin,
and glycine powder air polishing
teeth (gingivitis) and dental implants
(periimplant mucositis).5,6 Accord-
ingly, periimplant mucositis appears
as a host response to bacterial invasion,
in the same way as gingivitis in relation
to natural teeth.7 Histological studies of
soft tissues have shown that inflamma-
tory infiltrations in the mucosa around
implants and the gingiva around natural
teeth have many features in common.8–10
However, if bacterial plaque accumu-
lates for more than 3 months, the
inflammatory infiltrate of the periimplant
mucosa is almost 3 times as great as in the
case of natural teeth.7,9 A meta-analysis
conducted by Atieh et al11 found
are not effective for the treatment of
periimplant mucositis. The only effec-
tive treatment seems to be the use of
toothpaste with 0.3% triclosan.
Conclusion: Definitions of peri-
implant mucositis vary in the liter-
ature, and no clear criteria have
been established regarding the
diagnosis and treatment of this
disorder. It highlights our lack of
uniform treatment and need to
establish additional research to
fully provide effective treatments
for this common condition. More,
larger, and longer-term RCTs are
needed in this periimplant disease.
(Implant Dent 2015;24:13–18)
Key Words: dental implant, periim-
plant mucositis, periimplant dis-
eases, inflammation, mechanical
debridement, chlorhexidine
periimplant mucositis to affect 63.4%
of the patients and 30.7% of the implants.
The protocols used to treat gingivitis
and periimplant mucositis are similar.
However, very few studies have ad-
dressed the treatment of periimplant
mucositis.12–17 A number of therapies
have been used in application to periim-
plant mucositis, including antiseptic
agents,15,16,18–20 the administration of anti-
biotics,17 the use of glycine powder air
polishing (GPAP),21 or sodium carbonate
abrasive air powdering.14,22
The purpose of this study was to
systematically review the current liter-
ature and determine the most effective
 14 PERIIMPLANT MUCOSITIS
ATA-ALI ET AL

treatment for periimplant mucositis in Search Strategy for the Identification
patients with dental implants compared of Studies
with a control group. The PubMed (MEDLINE) data-
base of the United States National
Library of Medicine was used to con-
MATERIAL AND METHODS duct a literature search of articles pub-
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mucositis,” “peri-implant mucositis
treatment,” “humans,” “mechanical
debridement,” “non-surgical treat-
ment,” “RCT,” and “controlled clinical
study”. Two examiners read the titles
and abstracts of all studies, and no

The Preferred Reporting Items for lished up until October 2013. The blinding was carried out regarding the
Systematic Reviews and Meta-Analysis following search terms were used in names of the authors, journals and pub-
different combinations: “peri-implant lication date. The search was completed
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statement was used in this report.

Idenficaon
Screening
Eligibility
Included

Fig. 1. Prisma flow diagram of the searching processes and results. Seven RCTs were seen to meet the inclusion criteria and were thus
selected for inclusion in the systematic review.
 IMPLANT DENTISTRY / VOLUME 24, NUMBER 1 2015 15

with a review of the references of the
selected articles to identify additional
studies not found in the initial literature
search.
In addition, a manual search (up
until October 2013) was made of the
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Oral y Cirugía Bucal, and Oral Surgery,
Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontology.
Study Screening Criteria
Before starting the study, a series of
retrospective studies, and articles pub-
lished as abstracts only; (3) studies on
peri-implantitis; (4) studies failing to
specify the diagnostic criteria of periim-
plant mucositis or the duration of
follow-up. No restrictions were placed

following journals: Clinical Implant inclusion and exclusion criteria were on the year or language of publication.
Dentistry and Related Research, Clini- established. Full-text articles chosen Authors were contacted for clarification
cal Oral Investigations, Clinical Oral were assessed for the following inclu- of missing information when necessary.
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Implants Research, European Journal
of Oral Implantology, Implant Den-
tistry, International Journal of Oral
and Maxillofacial Implants, Journal of
Clinical Periodontology, Journal of
Oral Implantology, Journal of Peri-
odontology, Medicina Oral, Patología
sion criteria: (1) patients with at least 1
dental implant presenting signs of peri- Quality Assessment
implant mucositis; (2) follow-up for at The methodological quality of the
least 3 months; and (3) randomized studies was assessed according to the
controlled trials (RCTs). The following levels of evidence (University of
exclusion criteria were applied: (1) non- Oxford Centre for Evidence Based
randomized studies; (2) case series, Medicine)23 and the Jadad scale,

Table 1. Description of the 7 Studies Included in the Systematic Review

No. patients/No. Follow-up
implants (Study vs Period
Study Definition of Periimplant Mucositis Treatment (Study vs Control) Control) (mo)
De Siena et al20 BOP with or without swelling and 1% CHX gel twice a day for 10 days 13/d vs 10/d 3
redness. Periimplant bone versus 0.2% CHX rinse twice a day
resorption ,3 mm for 10 days
Ji et al21 PD $4 mm and BOP positive. No Supragingival scaling, root 12/17 vs 12/16 3
detectable loss of supporting bone debridement and polishing versus
as compared with periapical implants in the test group were
radiographs further treated with GPAP*†
Hallström et al17 PD $4 mm combined with bleeding Mechanical debridement with titanium 22/22 vs 21/21 6
and/or pus on probing curettes + polishing using rubber
cups and polishing paste versus
mechanical debridement with
titanium curettes + polishing using
rubber cups and polishing paste +
azithromycin 4 days (500 mg at day
1 and 250 mg at days 2–4)
Heitz-Mayfield Bleeding on light probing with no loss Mechanical treatment + 0.5% CHX 15/15 vs 14/14 3
et al18 of supporting bone gel versus mechanical treatment +
placebo gel
Thöne-Mühling BOP and/or a gingival index $1 at Treatment of remaining teeth (SRP + 6/22 vs 5/14 8
et al16 least at 1 site at baseline, and tartrectomy) versus SRP + 1% CHX
absence of periimplant bone loss gel applied once subgingivally +
during the last 2 years before dorsum of the tongue brushed for
baseline 1 minute with 1% CHX gel + each
tonsil was sprayed 4 times with
0.2% CHX spray + rinse twice for
1 minute with 0.2% CHX solution‡
Ramberg et al15 Bleeding after probing 0.3% triclosan toothpaste versus 30/d vs 29/d 6
sodium fluoride toothpaste
Porras et al19 Presence of supragingival and 0.12% CHX gel + 0.12% CHX rinse 16/16 vs 16/12 3
subgingival plaque; PD #5 mm, versus AT alone
showing evidence of inflammation
as measured with the modified
sulcus bleeding index
*GPAP (AIR-FLOW master and AIR-FLOW Perio; EMS, Nyon, Switzerland).
†All the implants were treated using ultrasonic scalers with carbon fiber tips (Satelec P5 ultrasonic scaling machine and PH2L, PH2R tips; Newtron, France).
‡The implants were cleaned using plastic scalers (Nobel Biocare) and polyetheretherketone-coated ultrasonic instruments (Piezon Master; EMS).
AT indicates antiseptic therapy including mechanical cleaning, using rubber cups and polishing paste, plastic scalers for removing calculus, and the provision of oral hygiene instructions; CHX,
chlorhexidine; SRP, scaling and root planing.
 16 PERIIMPLANT MUCOSITIS
ATA-ALI
referred to the method of randomiza-
tion, allocation concealment, blindness
of examiners, and completeness of
follow-up.24 Two authors indepen-
dently assessed the methodological
quality of the studies, and discrepancies
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were discussed between them to reach
consensus. Those studies scoring #2
points were considered to be of low
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quality, whereas $3 points were indic-
ative of high quality.24
RESULTS
Study Screening
The combinations of search terms
resulted in a list of 371 titles. Of these,
257 were found to be duplicated. To
avoid reviewing duplicate articles, we
remove any articles that appear more
than once. As a result, 114 references
were finally reviewed. All articles
included in the review were RCTs and
were published in English. One publi-
cation was excluded on applying the
defined screening criteria: the study
published by Corbella et al25 was not
an RCT. Finally, 7 RCTs were seen to
meet the inclusion criteria and were thus
selected for inclusion in the systematic
review (Fig. 1). The characteristics of
these 7 studies are summarized in
Table 1.
Assessment of Study Quality
The assessment of the methodolog-
ical quality of each article is summa-
rized in Table 2. Of the 7 RCTs included
in the systematic review, 3 studies19–21
were considered to be of low quality,
Table 2. Assessment of the Methodological Quality of Each Article
Porras
Quality Criteria et al19
I Yes
II No
III No
IV No
V No
Jadad score 1 4
Quality of study Low
Levels of evidence 2b
(CEMB 2011)
I: Was the study described as random?
II: Was the randomization scheme described and appropriate?
III: Was the study described as double blind?
IV: Was the method of double blinding appropriate?
V: Was there a description of dropouts and withdrawals?
ET AL
with Jadad scores of #2. Four stud-
ies15–18 were of relatively high quality,
with Jadad scores of $3. As regards the
level of evidence assessment, 4 stud-
ies15–18 were ranked as level 1b and 3
studies19–21 as level 2b.
Description of the Studies
Porras et al19 placed 28 implants in
16 patients; the study group underwent
mechanical cleaning, and instructions
were provided on oral hygiene, with
the prescription of 0.12% chlorhexidine
as a gel and rinse. The control group
likewise underwent mechanical clean-
ing, and instructions were provided on
oral hygiene, but without the use of
chlorhexidine. After a follow-up period
of 3 months, no statistically significant
differences were observed between the
2 groups. Heitz-Mayfield et al18 placed
29 implants in 29 patients and studied
the effect of 0.5% chlorhexidine gel
versus the administration of placebo
gel (control group). After a follow-up
period of 3 months, a decrease in peri-
implant mucositis was observed in both
groups, with no statistically significant
differences associated with the use of
chlorhexidine. Thöne-Mühling et al16
in turn placed 36 implants in 13 pa-
tients. The study group received 1%
chlorhexidine gel applied once subgin-
givally, the dorsum of the tongue was
brushed for 1 minute with 1% chlorhex-
idine gel, each tonsil was sprayed 4
times with 0.2% chlorhexidine spray,
rinsing was performed twice for 1 min-
ute with 0.2% chlorhexidine solution,
and the implants were cleaned using
Ramberg Thöne-Mühling Heitz-Mayfield
et al15 et al16 et al18
Yes Yes Yes
No Yes Yes
Yes No Yes
Yes No Yes
Yes Yes Yes
3 5
High High High
1b 1b 1b
plastic scalers and polyetheretherketone-
coated ultrasonic instruments. The
control group received the same treat-
ment but without the administration
of chlorhexidine. Although a decrease
in bacterial flora was observed in
the first 24 hours in the patients
treated with chlorhexidine, no sta-
tistically significant results were
obtained after 8 months of follow-up.
De Siena et al20 studied the effect of
chlorhexidine in 23 patients, comparing
2 forms of presentation: 1% chlorhexi-
dine gel twice a day for 10 days and
0.2% chlorhexidine rinse twice a day
for 10 days. After a follow-up period
of 3 months, plaque accumulation was
found to differ significantly between the
2 groups. The bleeding index and prob-
ing depth (PD) were not significantly
different between the 2 groups. Another
study15 involving 59 patients analyzed
the effect of toothpaste with 0.3% tri-
closan (in 30 patients) versus sodium
fluoride toothpaste (in 29 controls).
After a follow-up period of 6 months,
BOP was seen to have decreased in the
study group from 53.8% to 29.1%,
whereas in the control group, the values
increased from 52.3% to 58.8%.
The changes in BOP and PD were sta-
tistically significant. Plaque accumula-
tion was not significantly different
between the 2 groups. The authors
concluded that the continuous use of
toothpaste with 0.3% triclosan results
in significant reduction of periimplant
inflammation.
In an RCT17 involving 43 patients
with periimplant mucositis, the study
Hallström De Siena
et al17 Ji et al21 et al20
Yes Yes No
Yes Yes Yes
No No No
No No No
Yes No Yes
3 2 2
High Low Low
1b 2b 2b

group received mechanical debride-
ment with titanium curettes, polishing
using rubber cups, polishing paste,
and the administration of azithromycin
during 4 days (500 mg the first day, and
250 mg the next 3 days). The control
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group received mechanical debride-
ment with titanium curettes, polishing
using rubber cups and polishing paste.
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No decrease in bacterial burden was
observed after 3 months of follow-up.
After 6 months, BOP and PD were
seen to have decreased as a result of
improved oral hygiene. These authors17
advised nonsurgical debridement with-
out the administration of systemic anti-
biotics as the treatment of choice for
periimplant mucositis. Finally, Ji
et al21 placed 33 implants in 24 patients
and studied the effect of GPAP versus
a control group subjected to supragin-
gival scaling, root debridement, and
polishing. No statistically significant
results were observed after a follow-
up period of 3 months.
DISCUSSION
The purpose of this study was to
determine the most effective treatment
for periimplant mucositis in patients
with dental implants compared with
a control group. Four16,18–20 of the 7
RCTs included in the systematic review
examined the effect of chlorhexidine in
the treatment of periimplant mucositis,
and none of them obtained statistically
significant results. Of the remaining 3
RCTs included in the review, signifi-
cant reduction of the signs of periim-
plant inflammation were only recorded
after the continuous use during 6
months of toothpaste with 0.3% triclo-
san.15 In contrast, no statistically signif-
icant results were obtained in the
treatment of periimplant mucositis with
either GPAP21 or the administration of
azithromycin through the systemic
route.17 We contacted the authors of
the article published by De Siena
et al,20 who confirmed that the study
was an RCT, despite the fact that the
article describes the work as an “obser-
vational study”. We finally included
this publication in the systematic
review as an RCT.
Lang et al26 concluded that gingivi-
tis and periimplant mucositis are not
IMPLANT DENTISTRY / VOLUME 24, NUMBER 1 2015
clearly different from the pathogenic
perspective. Both diseases represent
a host response to the bacterial chal-
lenge generated by biofilm formation.
The infectious etiology of periimplant
mucositis is well documented.26–28 A
study29 involving 34 patients with 77
dental implants (comprising 23 muco-
sitis and 54 healthy periimplant sites)
concluded that bacterial plaque induces
an inflammatory response that can lead
to the development of periimplant mu-
cositis. Adequate plaque control is
therefore able to increase periimplant
health, avoiding the risk of future
complications.29 Because periimplant
mucositis represents the obvious pre-
cursor of peri-implantitis, in the same
way that gingivitis is a precursor to pe-
riodontitis, the treatment of mucositis
must be the prerequisite for the preven-
tion of peri-implantitis.26
In an experimental study conducted
by Trejo et al10 in cynomolgus monkeys
comparing mechanical debridement ver-
sus mechanical debridement with 0.12%
chlorhexidine application, no statisti-
cally significant differences were found
between the 2 groups. Another study25
demonstrated that a strict implant main-
tenance protocol can prevent the devel-
opment of peri-implantitis, and that
periimplant mucositis can be success-
fully treated through professional oral
hygiene combined with the use of chlo-
rhexidine as an antimicrobial agent.
Other authors30,31 consider that GPAP
can eliminate bacterial plaque in areas
that are scantly accessible to mechanical
debridement (situations with deep pock-
ets or narrow defects). Máximo et al14
and Duarte et al22 in turn reported sodium
carbonate abrasive air powdering to be
an effective treatment. The mechanical
elimination of bacterial plaque improves
but does not fully eliminate inflamma-
tion of the periimplant mucosa.13 For this
reason, the use of coadjuvant treatments
such as chlorhexidine16,18,20 or sodium
carbonate abrasive air powdering has
been proposed.14,22 The meta-analysis
published by Gunsolley32 on the effect
of triclosan demonstrated both anti-
plaque and antigingivitis effects in 18
studies, in concordance with our own
observations.
The main limitation of our study is
the small number of articles that were
17
available for review. A variable to be
taken into account in the interpretation
of the results is the fact that 4 of the 7
RCTs were of high quality, with level of
evidence 1b. The aim was to conduct
a meta-analysis to evaluate the effec-
tiveness of periimplant mucositis treat-
ment. This was not possible mainly due
to the following: (1) Lack of homoge-
neity in defining periimplant mucositis.
In effect, each study used a different
definition, and we therefore accepted
the definition used by the authors in
each publication; (2) The treatments
used in the studies differed in relation
to the mechanical procedures involved,
the form of presentation, dosage, the
treatments of the control groups, and the
duration of follow-up.
CONCLUSION
In conclusion, the analysis of the 7
RCTs included in the present system-
atic review shows that chlorhexidine,
the administration of azithromycin
through the systemic route, and GPAP
are not effective for the treatment of
periimplant mucositis over the long
term. The only effective treatment iden-
tified was the use of toothpaste with
0.3% triclosan. An adequate level of
oral hygiene is needed. Definitions of
periimplant mucositis vary in the liter-
ature, and no clear criteria have been
established regarding the diagnosis and
treatment of these disorders. More
RCTs involving larger sample sizes
will be needed to establish the most
effective treatment option for this
disease.
DISCLOSURE
The authors claim to have no
financial interest, either directly or
indirectly, in the products or informa-
tion listed in the article.
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