Peri-implantitis revised

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General Comment
Has the journal a high impact factor?
This journal is indeed a high impact factor for pre-implants are becoming an oral health concern due to the growing number of dental implants. The European Federation of Periodontology estimates that 80% of individuals undergoing dental implants are likely to develop peri-implantitis. Among those patients, 50% of the implants develop peri-implant mucositis. This condition is greatly influenced by the patients’ general oral hygiene, smoking, systemic health conditions and medication. Such unhygienic oral health conditions may favor bacteria colonization on the mucous membrane resulting in inflammation of the area adjacent to the implant. Despite the consequences and magnitude of peri-implantitis, an effective and universal treatment procedure is yet to be agreed upon.
Is the title complete and appropriate compared to the article content?
All the four studies included in this meta-analysis tend to compare the laser mode and the SMD mode of treating peri-implantitis. This meta-analysis came up with a general title that suitably incorporates the four studies and their respective contents. The four studies examined common parameters devised to analyze both modes of treatment.
Does the abstract correspond to the article content? Is there any conflict of interest?
The meta-analysis abstract, adequately covered the four studies included in the meta-analysis while concentrating much on analyzing the accuracy of the data in these studies.

It also critically analyses both primary and the secondary outcomes in each case. The meta-analysis concluded that the laser mode has short-term benefits compared to SMD mode. However, there was no concrete evidence to prove that the laser mode is superior in the long run.
Critical analysis of the abstract
Sufficient?
The abstract in the meta-analysis adequately covered the four randomized clinical test comparing the two modes of treating peri-implantitis. According to the meta-analysis of the four studies to establish the clinical effectiveness of ER: Yag laser over the traditional SMD mode of treatments remains unclear.
Does it match the title?
The central objective of this meta-analysis is to use the first-hand clinical data to establish if indeed the laser treatment is superior to SMD. It singled-out only four studies (20, 21, 26 and 35) out of the 120 studies which were able to meet the threshold for the set inclusion/exclusion criteria. In each study, results obtained from the parameters tested were presented as a weighted mean difference.
Truthful?
This meta-analysis critically analyzed the four selected studies with the aim of establishing the superiority of Er: YAG over the traditional SMD modes of treatments. The four studies included were objectively designed to evaluate whether this statement is true. Inclusion and exclusion criteria used to select patients as well as the recording and calculations were done with the aim of obtaining the most accurate results to help in coming up with a universally agreed conclusion on this topic of study.
Introduction
Is the background presented in the introduction updated, correct and complete?
The background presented in the introduction highlights all the concrete information about the peri-implant disease, identifying various causes and treatment through a research study. The background study captures the statistics about the peri-implant disease, and it is a broad term that incorporates all the disorders resulting from implant dentistry. These disorders, including peri-implant mucositis and peri-implants are bacterial inflammatory defects occurring in the immediate implant surrounding tissues. The introduction stresses on more research and scientific evidence to prove whether the laser treatment technique is superior than the SMD technique. In addition to establishing the laser efficiency, it also stresses the need to establish the clinical safety of the laser treatment technique. The four studies did not find adverse conditions attributable to any of the two modes of treatment.
Materials and method
How many patients/samples?
This meta-analysis incorporated four controlled clinical studies [20, 21, 26, and 35] published between 2005 and 2012. The studies had a total number of 92 patients who are above the age of 18 years. The study [20] consisted of 32 patients with a total of 35 dental implants. The average age of the patients in this study was 60.8 ± 10.9 y. They were to undergo a six-month follow-up from the time of treatment. The study [21] examined 20 patients with a total of 32 implants. Their average age was 48 y. In this study; patients were to undergo a six-month follow-up from the baseline. The study [26] included 20 patients with a total of 40 implants. They had an average of 56 ± 14 y. The patients in this study were to undergo a one-year follow-up (12 months). And finally, the study [35] included 24 patients with a total of 26 implants. Patients in this study had a mean age of 62 ± ten years and underwent a twelve month follow-up from the day of treatment. The four randomized clinical tests investigated a total of 126 implants from the 92 patients. The patients underwent varied types of implant involving a variety of titanium screw types (including SLA and TPS screw-types).
Are they enough?
The number of patients examined in each of the four studies is small due to the protocols used to include them in the study. Also, the small amount of pooled studies included in the meta-analysis contributed greatly to the small number of participants. The criteria for inclusion used in every single study was strictly followed thus significantly reducing the number of patients examined. Quality of results was the central objective of the meta-analysis in its inclusion criteria. Basing on the fact that the studies aimed at obtaining the highest quality results, they should also focus on increasing the number of the participant for more significant and comparative results.
Were they chosen correctly?
The patients included in the four studies were correctly chosen since it followed such aspects as gender balance. Also, all the four studies randomly included patients suffering from acute and advanced peri-implant lesions. All the four studies took the patients through a prior informatory process to teach them about procedures involved in the exercise. The local ethical committee approved all the four studies. The process of grouping the patients to undergo the two treatment techniques investigated was random and was done regardless of the age and the severity of the peri-implant lesion.
What kind of study is this? Is it blinded? (What kind of blinding- single or double blinding)
This comparative studies included in this meta-analysis are blinded studies. This is because it involves a clinical test. Furthermore, the studies in this meta-analysis are single-blinded studies since the examiner knows which group is taking an active medication but not the patient.
Are the criteria for inclusion and exclusion clearly listed and detailed?
The criteria used for inclusion in the four studies selected were listed and explained in details for the four studies included in this meta-analysis. Also, the criteria used for inclusion of the studies in this meta-analysis were defined. The common criteria for inclusion for the four studies require that: the patient must be a non-smoker, must not have been under antibiotics for the last six months from the time of treatment as a result of a systemic illness. The patient is also required not to have been in any per-iimplantitis treatment for the last one year before the baseline. However, the probing depth (PD) minimum requirement varies between the studies. The study [20] set a slightly higher minimum requirement of more than 6 mm depth compared to the other studies which have set at > 4 mm.
Are sample/patients divided into comparable groups?
In each study included in the meta-analysis, patients were put into two groups with equal numbers. The two groups were to undergo Er: YAG laser treatment and the other to undergo the subgingival mechanical treatment (SMD). Results obtained in each group were compared objectively to determine the superiority of one mode of treatment over the other. Parameters examined in both groups included: the probing depth (PD), bleeding on probing (BOP), clinical attachment level (CAL), gingival recession (GR), and plaque index (PI). In the meta-analysis, clinical attachment level and the probing depth were categorized as the primary outcomes of both the SMD and ER: YAG groups in all the four studies between the sixth and the twelfth month after the day of treatment. On the other hand, gingival recession is considered as the secondary outcome on the same period. These control studies were carried out to establish the effectiveness of Er: YAG laser treatment over the old model of peri-implantitis treatment, subgingival mechanical debridement, therefore, SMD group is the control group and the Er: YAG is the test group.
Is there any control group?
In the study [20], the test group included 15 patients, and the control group included 15 patients. The study [21] included an equal number of patients in both the control and test groups.
The study [26] included ten patients in the test group and ten others in the control group. The study [35] included ten patients in the test group and 14 in the control groups thus becoming the only group with unevenly distributed patients.
Are the lasers used correctly?
According to the outcome obtained from these four studies, Er: YAG is effective and reliable in peri-implantitis treatment process. Titanium elements poorly absorb the laser wavelength of 2.94µm therefore not damaging its rough surface. It was also established that the temperature of the implant does not increase as a result of Er: YAG laser irradiation (Schwarz et al. 45). The high temperature could increase the bactericidal effect of the laser, but it is kept below 47 o C to avoid damaging the implant tissue. The Er: A YAG group BOP outcomes at the end of six months proves that the laser parameters were reliable in eliminating bacterial biofilms on the rough titanium surface.
Are the laser parameters complete and reliable? Were they chosen appropriately?
The laser parameters were set correctly since no case of irradiation was reported among the Er: YAG group patients in all the four studies. In all the studies included in this meta-analysis, laser parameters were set as 10 Hz frequency, 2.94 µm wavelength, and 100 mJ/pulse energy level. The infrared beam was pointed to the lesion with the help of a periodontal hand-piece and a glass fiber emitting axial and radial laser beams. The glass fiber tip emitting the radiation was moving in a circular motion on the implant surface in contact mode. At the end of the follow- period (6 and 12 months), the patients in all the four studies have not experienced any tissue damage in the area adjacent to the osseointegrated implant.
Are all calculations correct?
The data recorded in the studies included in this meta-analysis have a high degree of accuracy. According to the asymmetry test done on all the four studies, there were also no publication biases. Heterogeneity of the results of the four studies after six months from the baseline was 11% and 0% after twelve months. The data obtained is recorded in a Microsoft Office Excel file which indicates a high degree of accuracy of the calculation done therein. The trim-and-fill method used did not show any difference in original and derived data in the sixth and twelfth-month data.
Results
Are the results complete and detailed?
The results of the individual studies included in this meta-analysis show accuracy, and completeness of the data in the parameters examined. Individual groups were well singled out to serve the requirements of the topic of study. This meta-analysis employed a strict inclusion and exclusion criteria in its evaluation of the most suitable studies to serve the particular topic of study. Among the areas assessed are, publication bias, the risk of bias and heterogeneity. The searching process involved and a large-scale strategy which is not restricted by language and geographic location.
Are the results objectively evaluated?
The studies included in this meta-analysis produces results needed to serve appropriately in this topic of study. In the four studies, parameters examined by the instructors are the same and aimed at determining Er: YAG laser effectiveness in the treatment of peri-implantitis over the traditional SMD method. The primary outcomes for this meta-analysis were the changes in probing depth and the clinical attachment level over the period of 6 and 12 months from the time of treatment. The secondary outcome was the gingival recession at the same time. For the first six months, a greater CAL gain was recorded among the Er: YAG group as compared to the SMD group. Though this was not a much significant difference
Is the statistical analysis correct and reliable?
The studies included in this meta-analysis registered accurate and well-presented data. The information was stored and critically analyzed using SPSS and Microsoft Office Excel computer application software. This ensures a high degree of accuracy since the error can only be recorded during the data entry process. The meta-analysis also established the accuracy of data included in the studies. It tested the risk of bias, the risk of publication bias, and heterogeneity of these studies. The selected studies were also assessed to ascertain that they meet the threshold set by the inclusion criteria both of the study and the patients examined by the study.
Discussion
Is the discussion appropriate to the study?
The discussion in all the study revolves around the effectiveness of Er: YAG over SMD peri-implantitis treatment techniques. Therefore, it is suitable for the topic of study and serves the indented purpose of this meta-analysis. The meta-analysis evaluates and compares parameters of the four studies and analyzes them into details for better comparisons. According to the meta-analysis findings, the laser treatment shows significant results in the first six month and limited improvement in the other six months.
Are comments well referenced?
The meta-analysis comments were well referenced to their respective studies. It shows the following findings concerning the studies evaluated: Study [21] indicated that there were better improvements on the scene treated using the ERL technique. The study [26], emphasizes that improvements achieved by patients treated with irradiations were just manifested within the first six months. The meta-analysis also gives comparisons between the various studies basing on parameters as illustrated below: Study [21, 20 & 26] did not register any CAL gain. Study 21 and 26 indicated that there was a significant reduction of BOP among patient treated using the laser. In study 20 and 35 there were no indications of significant reduction of BOP emphasized by the other two studies.
Is the extent of discussion appropriate to the objective of the study?
The objective of this meta-analysis is to determine the effectiveness of the laser treatment over the traditional SMD treatment. The respective studies included also focus on establishing the truth in this topic of study. Instructors carrying out these studies focused on obtaining first-hand results of the clinical parameters that were set to be examined. The discussions of various studies tend to compare and contrast the data obtained from parameters of the two groups (SMD and Er: YAG) with the central objective of establishing superiority.
Are there ethical issues regarding the study?
The meta-analysis included studies that were approved by their respective local ethical committee before their commencements. Throughout the exercise of the four studies, no ethical issues were surrounding the treatment. There was no discrimination in the inclusion and grouping criteria used by the patients. The main clinical equipment introduced in the test group is the laser gadget which was already used in other surgical operations for disinfection. After treatment exercise, there was no adverse complication reported which can directly be associated with the two modes of treatments.
Conclusion
Is the conclusion reached accurately?
The four studies came up with different conclusions regarding the effectiveness of the laser mode of treatment. According to this analysis, all the studies involved in this exercise did not provide evidence of the long-term effectiveness of the laser technique compared to the traditional SMD technique. Also, all the studies recorded significant reduction of BOP amount the Er: YAG group compared to the SMD group. The meta-analysis concludes that the laser mode can only be an alternative to SMD since no evidence of long-term benefits were recorded in all the studies. It also suggests the need for more research on the topic to enable the development of a universally agreed fact on this topic of study.
Strengths
One of the strengths of this analysis includes its ability to focus on the accuracy of the data provided by the four studies. This resulted in the individual studies having few participants. Secondly, the criteria for inclusion and exclusion of these studies were strictly followed. This resulted in a small number of pooled studies. The studies were critically analyzed for the risk of publication bias and heterogeneity.
References
Are they up to date? Are they papers published on high impact factor journal?
These series of studies carried out by Schwarz et al. between 2005 and 2012. They are the latest studies carried out and most relevant to this topic of study thus they are up to date. The massive digital search carried out in the journals relating to this topic found the four articles to be most suitable for this discussion. These are high impact journals since they seek to find a solution to the global oral health concern.
Weakness
The article main weakness is its inability to come up with a clear conclusion about the topic of study. It cites the limited studies included in the analysis as the main reason for lack of a concrete and universally agreed on conclusion concerning this topic of study.
Flows of the study
The studies included in this meta-analysis recorded a general, less significant difference in the result between the evaluated groups. This phenomenon can be attributed to the limited number of participants and pooled studies. Results may be influenced by some factors, such as the number of dental implants of each patient. The type of implant of individual patients is another major factor that can influence the parameter measurements. The age of the implant, as well as the age of the individual patients, may also influence the results. Nevertheless, some patient exhibits allergic reactions to some medical treatments. For instance, the patients who had a continuous formation of pus after being put under CHX treatment had an allergy to CHX. Instructors of these studies should have taken these factors into consideration and group the patient basing on these factors.
Works cited
Schwarz, Frank, et al. “Clinical evaluation of an Er: YAG laser for nonsurgical treatment of peri‐implantitis: a pilot study.” Clinical oral implants research 16.1 (2005): 44-64.
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