Diederik Hentenaar

155 General discussion and conclusions taking into account various confounding factors such as implant depth, width of occlusal table, implant diameter or implant design, implant abutment connections or abutment design, in implants with marginal bone loss of 3 mm and more. Concluding remarks and future perspectives The current thesis underlines the notion that peri-implantitis is a difficult disorder to treat. To date, clinical approaches using single mechanical, chemical or combined methods in the (non-regenerative) treatment of peri-implantitis, remain (very) limited successful. With the evolution of titanium implant surfaces becoming increasingly complex, focused on better and faster osseointegration, returning a contaminated implant surface into a clean ‘rejuvenated’ pre-implantation status has turned out a challenging task (Sanz, Chapple 2012, Lee et al. 2018, Lollobrigida et al. 2020, Tong et al. 2021). New studies remain urgently required to find the optimum combination of different cleansing methods that compensate for each method’s respective downsides, with study protocols combining non-surgical and (resective or regenerative) surgical procedures (Sanz et al. 2019, Alarcón et al. 2021). But, more importantly, peri-implant disease should be diagnosed early and ideally be prevented to save both patient and clinician a significant amount of time, money, effort and frustration. In addition, patients systematic implant aftercare programs are of critical importance (Ramanauskaite & Tervonen 2016). Patients should should be strongly recommended and frequently remotivated to comply with an aftercare program (Mitschke et al. 2020). Methods which recently appeared in the literature with promising effects on reduction of the bacterial load on titanium surfaces, but rigorously needs to be confirmed in clinical trials, are for example the use of photodynamic therapy (Lopez et al. 2020), leukocyte- and platelet-rich fibrin (Schuldt et al. 2021), cold plasma (Hui et al. 2021, Jungbauer et al. 2021) or an electrolyte device (Schlee et al. 2019). Especially on this latter (electrolyte) device, which efficacy is based on the generation of hydrogen bubbles that lifts the biofilm off the implant surface, significant effects were reported in an in- vitro setting (Ratka et al. 2019). It was shown that the electrolyte approach inactivated the bacterial biofilm without leaving reproducible bacteria behind. Clinically, this device has thus far only been described one time in a regenerative approach, lacking a true control group (the control group consisted of the same device in a combined method with air-polishing instead of an approach without the device). Hence, greater sample size studies with longer follow-up needed to confirm the pre-clinical findings on this device. Another (resective) method which also gains more attention in the recent literature is removal of the implant threads by means of rotatory instruments and/or polishing stones, i.e. implantoplasty. Although some studies show promising outcomes (Monje et al. 2021), there is much concern regarding this procedure in terms 7