<table><caption>TABLE 6 Primordial prevention actions reported in the selected studies.</caption><thead><tr><th>Variable</th><th>Oral hygiene instructions given prior to implant placement</th><th>Achievement of optimal plaque control prior to implant placement</th><th>Achievement of low gingival inflammation prior to implant placement</th><th>Treatment(s) of periodontal disease prior to implant placement</th><th>Promoting smoking cessation</th><th>Promoting adherence to periodontal and peri-implant supportive care</th><th>Promoting/ monitoring glycaemic control</th></tr></thead><tbody><tr><td><strong>Reference</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Glycaemic control</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Tawil et al. (2008)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td></tr><tr><td>Aguilar-Salvatierra et al. (2016)</td><td>✓</td><td>✓</td><td>-</td><td>✓</td><td>Smoking as exclusion criterion</td><td>-</td><td>✓</td></tr><tr><td>Ghiraldini et al. (2016)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>Smoking as exclusion criterion</td><td>✓</td><td>✓</td></tr><tr><td>Gomez-Moreno et al. (2015)</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>✓</td></tr><tr><td>Al Amri et al. (2016)</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>✓</td></tr><tr><td>Abduljabbar et al. (2017)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>✓</td></tr><tr><td>Alrabiah et al. (2018)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>-</td></tr><tr><td>Al-Sowygh et al. (2018)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>-</td></tr><tr><td>Alsahhaf et al. (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>✓</td></tr><tr><td>Al Zahrani and Al Mutairi (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>✓</td></tr><tr><td>Mokeem et al. (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>✓</td></tr><tr><td><strong>Smoking cessation strategies</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>AlQahtani et al. (2018)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>ArRejaie et al. (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Alqahtani et al. (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Costa et al. (2022)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td><strong>Supportive care protocols/compliance</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Ferreira et al. (2006)</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>-</td></tr><tr><td>M. Rocuzzo et al. (2010, 2012)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr></tbody></table>
<table><caption>TABLE 6 (Continued)</caption><thead><tr><th>Variable</th><th>Oral hygiene instructions given prior to implant placement</th><th>Achievement of optimal plaque control prior to implant placement</th><th>Achievement of low gingival inflammation prior to implant placement</th><th>Treatment(s) of periodontal disease prior to implant placement</th><th>Promoting smoking cessation</th><th>Promoting adherence to periodontal and peri-implant supportive care</th><th>Promoting/ monitoring glycaemic control</th></tr></thead><tbody><tr><td>Reference</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Rinke et al. (2011)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Aguirre-Zorzano et al. (2013)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Roccuzzo et al. (2014, 2022)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Monje et al. (2017)</td><td>✓</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Ziebolz et al. (2017)</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Roman-Torres et al. (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Frisch et al. (2020)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Hu et al. (2020)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Alhakeem et al. (2022)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Peri-implant soft tissue augmentation</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lorenzo et al. (2012)</td><td>✓</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Frisch et al. (2015)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>Smoking as exclusion criterion</td><td>✓</td><td>-</td></tr><tr><td>Basegmez et al. (2013)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Linkevicius et al. (2015)</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Buyukozdemir Askin et al. (2015)</td><td>✓</td><td>✓</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>-</td></tr><tr><td>Roccuzzo et al. (2016)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Bienz et al. (2017)</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Cairo et al. (2017)</td><td>-</td><td>✓</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Oh et al. (2017, 2020)</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Vellis et al. (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Hosseini et al. (2020)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Huang et al. (2021)</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>-</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 6 (Continued)</caption><thead><tr><th>Variable</th><th>Oral hygiene instructions given prior to implant placement</th><th>Achievement of optimal plaque control prior to implant placement</th><th>Achievement of low gingival inflammation prior to implant placement</th><th>Treatment(s) of periodontal disease prior to implant placement</th><th>Promoting smoking cessation</th><th>Promoting adherence to periodontal and peri-implant supportive care</th><th>Promoting/ monitoring glycaemic control</th></tr></thead><tbody><tr><td>Reference</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Rinke et al. (2011)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Aguirre-Zorzano et al. (2013)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Roccuzzo et al. (2014, 2022)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Monje et al. (2017)</td><td>✓</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Ziebolz et al. (2017)</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Roman-Torres et al. (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Frisch et al. (2020)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Hu et al. (2020)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Alhakeem et al. (2022)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Peri-implant soft tissue augmentation</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lorenzo et al. (2012)</td><td>✓</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Frisch et al. (2015)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>Smoking as exclusion criterion</td><td>✓</td><td>-</td></tr><tr><td>Basegmez et al. (2013)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Linkevicius et al. (2015)</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Buyukozdemir Askin et al. (2015)</td><td>✓</td><td>✓</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>-</td></tr><tr><td>Roccuzzo et al. (2016)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Bienz et al. (2017)</td><td>-</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Cairo et al. (2017)</td><td>-</td><td>✓</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Oh et al. (2017, 2020)</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Vellis et al. (2019)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>-</td></tr><tr><td>Hosseini et al. (2020)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Huang et al. (2021)</td><td>✓</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>✓</td><td>-</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 6 (Continued)</caption><thead><tr><th>Variable</th><th>Oral hygiene instructions given prior to implant placement</th><th>Achievement of optimal plaque control prior to implant placement</th><th>Achievement of low gingival inflammation prior to implant placement</th><th>Treatment(s) of periodontal disease prior to implant placement</th><th>Promoting smoking cessation</th><th>Promoting adherence to periodontal and peri-implant supportive care</th><th>Promoting/ monitoring glycaemic control</th></tr></thead><tbody><tr><td>Reference</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Zheng et al. (2021)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Thoma et al. (2020, 2022)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Kikuchi et al. (2022)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>✓</td><td>✓</td><td>-</td></tr><tr><td>Oral hygiene habits</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Truhlar et al. (2000)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Swierkot et al. (2013)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>Diabetes as exclusion criterion</td></tr></tbody></table>

Note: ✓ Reported in the article.

be made to promote smoking cessation in routine dental practice as recommended by recent guidelines (Herrera et al., 2022; Holliday et al., 2021; Sanz et al., 2020; WHO, 2017). However, this does not appear to have been performed in the selected studies; of the 48 studies, only in 3 the authors clearly stated that smoking cessation interventions were undertaken prior to implant placement, whereas in most of them (20/48) smoking was considered as an exclusion (or non-inclusion) criterion for patient selection, leaving essentially unexplored the impact of promoting smoking reduction or cessation prior to implant placement or after implant loading to prevent PIDs.

### 4.1.3 | Impact of adherence to SPC

The 14 studies dealing with SPC support, the cardinal role of regular SPC to maintain peri-implant health as well as dental implant survival was emphasized (Cortellini et al., 2019). Indeed, irregular or no SPC over time was associated with a significantly higher risk of peri-implantitis and worse clinical parameters at the patient and dental implant level. Interestingly, at the patient level, the occurrence of mucositis was not significantly different between groups. This may be due to the limited number of study/patients included in the meta-analysis or to the case definition of mucositis (e.g., based on clinical vs. radiographic examinations that did not show bone loss). Most of the studies included patients with a history of periodontitis (treated prior to implant placement), for whom SPC also plays a central role in preventing periodontitis recurrence (Sanz et al., 2020), which in turn may have an impact on peri-implant health (Carra et al., 2022; Cho-Yan Lee et al., 2012; Cortellini et al., 2019). Thus, considering the impact of irregular SPC on peri-implant health, effective and individualized SPC protocols should always be considered in case of dental implant placement and must include all preventive and therapeutic actions necessary to maintain peri-implant health (Sanz et al., 2020). Efforts should be made to increase the patient's knowledge about the importance of follow-up after implant therapy to increase motivation and adherence to SPC (Amerio et al., 2020).

### 4.1.4 | Impact of augmenting PIKM and peri-implant soft tissue thickness

Overall, there is no evidence to support peri-implant soft tissue augmentation procedures as effective preventive measures for PIDs. No study was designed to assess their role over time, and no conclusion can be drawn to date. However, implants receiving PIKM augmentation procedures showed lower peri-implant inflammation (BOP/GI) and lower MBL changes compared to implants with PIKM width deficiency, suggesting that effective keratinized tissue width augmentation procedures may contribute to maintaining peri-implant health. Few studies observed PIDs events (probably due to short follow-ups), and the incidence of PIDs was not different between augmented and non-augmented sites. Similarly, survival was reported in only three studies, and this hampers any clear conclusion. Concerning the type
<table><caption>TABLE 6 (Continued)</caption><thead><tr><th>Variable</th><th>Oral hygiene instructions given prior to implant placement</th><th>Achievement of optimal plaque control prior to implant placement</th><th>Achievement of low gingival inflammation prior to implant placement</th><th>Treatment(s) of periodontal disease prior to implant placement</th><th>Promoting smoking cessation</th><th>Promoting adherence to periodontal and peri-implant supportive care</th><th>Promoting/ monitoring glycaemic control</th></tr></thead><tbody><tr><td>Reference</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Zheng et al. (2021)</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Thoma et al. (2020, 2022)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Diabetes as exclusion criterion</td></tr><tr><td>Kikuchi et al. (2022)</td><td>-</td><td>-</td><td>-</td><td>✓</td><td>✓</td><td>✓</td><td>-</td></tr><tr><td>Oral hygiene habits</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Truhlar et al. (2000)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Swierkot et al. (2013)</td><td>-</td><td>-</td><td>-</td><td>-</td><td>Smoking as exclusion criterion</td><td>-</td><td>Diabetes as exclusion criterion</td></tr></tbody></table>

Note: ✓ Reported in the article.

be made to promote smoking cessation in routine dental practice as recommended by recent guidelines (Herrera et al., 2022; Holliday et al., 2021; Sanz et al., 2020; WHO, 2017). However, this does not appear to have been performed in the selected studies; of the 48 studies, only in 3 the authors clearly stated that smoking cessation interventions were undertaken prior to implant placement, whereas in most of them (20/48) smoking was considered as an exclusion (or non-inclusion) criterion for patient selection, leaving essentially unexplored the impact of promoting smoking reduction or cessation prior to implant placement or after implant loading to prevent PIDs.

### 4.1.3 | Impact of adherence to SPC

The 14 studies dealing with SPC support, the cardinal role of regular SPC to maintain peri-implant health as well as dental implant survival was emphasized (Cortellini et al., 2019). Indeed, irregular or no SPC over time was associated with a significantly higher risk of peri-implantitis and worse clinical parameters at the patient and dental implant level. Interestingly, at the patient level, the occurrence of mucositis was not significantly different between groups. This may be due to the limited number of study/patients included in the meta-analysis or to the case definition of mucositis (e.g., based on clinical vs. radiographic examinations that did not show bone loss). Most of the studies included patients with a history of periodontitis (treated prior to implant placement), for whom SPC also plays a central role in preventing periodontitis recurrence (Sanz et al., 2020), which in turn may have an impact on peri-implant health (Carra et al., 2022; Cho-Yan Lee et al., 2012; Cortellini et al., 2019). Thus, considering the impact of irregular SPC on peri-implant health, effective and individualized SPC protocols should always be considered in case of dental implant placement and must include all preventive and therapeutic actions necessary to maintain peri-implant health (Sanz et al., 2020). Efforts should be made to increase the patient's knowledge about the importance of follow-up after implant therapy to increase motivation and adherence to SPC (Amerio et al., 2020).

### 4.1.4 | Impact of augmenting PIKM and peri-implant soft tissue thickness

Overall, there is no evidence to support peri-implant soft tissue augmentation procedures as effective preventive measures for PIDs. No study was designed to assess their role over time, and no conclusion can be drawn to date. However, implants receiving PIKM augmentation procedures showed lower peri-implant inflammation (BOP/GI) and lower MBL changes compared to implants with PIKM width deficiency, suggesting that effective keratinized tissue width augmentation procedures may contribute to maintaining peri-implant health. Few studies observed PIDs events (probably due to short follow-ups), and the incidence of PIDs was not different between augmented and non-augmented sites. Similarly, survival was reported in only three studies, and this hampers any clear conclusion. Concerning the type
of soft-tissue augmentation procedures, no difference was observed for CTG, FGG, or XCM in terms of PPD, BOP, and MBL, but differences in the indication may exist. It is noteworthy that PIKM deficiency was defined differently among the selected studies, encompassing a width of PIKM of <1, 2, or 3 mm, and different techniques were applied. A high variability in the timeline at which the augmentation procedure was performed (before or after dental implant placement, simultaneously to the dental implant placement, at the stage 2 surgery, after dental implant loading, etc.) reflects the high clinical heterogeneity of the included studies. Most of the studies described clinical peri-implant outcomes in the short term (6-12 months follow-up), whereas only two observational studies reported the occurrence of PIDs over a 10- (M. Roccuzzo et al., 2016) and 12-year follow-up (Frisch et al., 2015). Therefore, care must be taken regarding the interpretation of the results, although pooled data analyses (and sensitivity analyses) suggest that augmented PIKM may contribute to peri-implant health, probably ensuring a more resistant peri-implant mucosal seal (Sanz et al., 2022), associated with lower biofilm accumulation, soft-tissue inflammation, mucosal recession, and MBL (Giannobile et al., 2018; Ramanauskaitė et al., 2022). This hypothesis should be verified in future studies involving soft tissue augmentation procedures performed with a preventive intent towards PIDs and should also specifically assess the benefits/harms ratio taking into account the invasiveness of the intervention and the expected benefits (risk reduction), which to date cannot be evaluated.

### 4.1.5 | Impact of oral hygiene behaviours

Very few studies investigated the impact of different oral health (OH) behaviours on peri-implant health and diseases. The three studies included were inconclusive about the type of toothbrush to use (e.g., powered or manual) or the frequency of toothbrushing that is most effective on peri-implant health. Further studies are awaited because OH remains the key factor to avoid plaque accumulation and peri-implant tissue inflammation (Fu & Wang, 2020). Specific and personalized OH instructions should be given to patients prior to implant placement, and then reviewed at each therapeutic step and when the final implant-supported restoration is loaded, to ensure adequate cleanliness of the prosthetic rehabilitation. This is a complex and difficult task for patients, requiring time, dexterity, and motivation.

## 4.2 | Methodological considerations and study limitations

As mentioned previously, no direct evidence was found assessing the efficacy of primordial and primary preventive interventions for PIDs. This represents the main limitation of the present systematic review and meta-analyses, whose findings are mainly derived from observational studies comparing exposed versus non-exposed groups of patients or two types of intervention not originally delivered to prevent PIDs. Thus, caution should be taken in the critical appraisal of

the results, particularly because we are mostly dealing with indirect evidence, heterogenous studies (in terms of design and working hypothesis), and almost 58% of included studies presented with moderate to high risk of bias. Moreover, only 33% of the studies declared whether funding was received or not, which may also represent a source of bias. Finally, most of the results were reported at the dental implant level only. There are many reasons to privilege the patient as a statistical unit. First, there is a philosophical consideration: we treat the patients, not implants. Second, there is a statistical consideration: dental implants are not independent of the teeth and of each other. Third, there is a medical consideration: when dealing with general health, such as glycaemic control or behaviours, such as smoking, the patient is involved.

Regarding primordial prevention, the lack of data is mainly due to a precise definition of what the ideal peri-implant health is. It seems that each author has a personalized prevention programme that best fits the type of study design. Several components should be included in the definition of the ideal peri-implant health that should be reached prior to dental implant placement.

Regarding primary prevention, another limiting factor is the duration of the follow-up, which was highly variable between the studies. In the present systematic review, a follow-up of a minimum of 6 months was set as a selection criterion; this may be a sufficient time lag to detect some signs of peri-implant inflammation but is likely too short to diagnose peri-implantitis. For this reason, most of the studies with a short-term follow-up did not report PID rates or did not observe any case of PIDs. This should be considered when interpreting the present results, knowing that the risk of PIDs may be dependent on the duration of the exposure to the risk factor(s) (e.g., smoking, poorly controlled diabetes, irregular SPC). Very limited data were available specifically on the prevention of peri-implant mucositis, a predictor of peri-implantitis, and various disease case definitions were used. Further, in the selected studies, several different dental implant brands and several different surgical protocols were applied, leading to considerable clinical heterogeneity, which must be taken into account in the critical appraisal of the results.

The biological factors evaluated in the present review were predetermined, based on the available evidence supporting their impact on the peri-implant tissues. It is possible that other unknown factors may have an effect on peri-implant health. PIDs are more likely to exhibit a multifactorial aetiology (Fu & Wang, 2020; Schliephake, 2022), in which several patient-, implant-, and clinician-related risk factors interact and contribute to the development of PIDs. If this model is accepted, the risk factor control should target all modifiable risk factors identified for a specific patient, meaning implementing multiple preventive interventions simultaneously to be effective in maintaining peri-implant health over time.

Finally, for complex diseases such as PIDs, considering that one isolated risk factor cannot cause a disease on its own and that a practitioner treats patients not dental implants, special attention should be paid to the statistical unit of analysis. PIDs should be explored at the patient level, and specific clinical diagnoses of peri-implantitis or
of soft-tissue augmentation procedures, no difference was observed for CTG, FGG, or XCM in terms of PPD, BOP, and MBL, but differences in the indication may exist. It is noteworthy that PIKM deficiency was defined differently among the selected studies, encompassing a width of PIKM of <1, 2, or 3 mm, and different techniques were applied. A high variability in the timeline at which the augmentation procedure was performed (before or after dental implant placement, simultaneously to the dental implant placement, at the stage 2 surgery, after dental implant loading, etc.) reflects the high clinical heterogeneity of the included studies. Most of the studies described clinical peri-implant outcomes in the short term (6-12 months follow-up), whereas only two observational studies reported the occurrence of PIDs over a 10- (M. Roccuzzo et al., 2016) and 12-year follow-up (Frisch et al., 2015). Therefore, care must be taken regarding the interpretation of the results, although pooled data analyses (and sensitivity analyses) suggest that augmented PIKM may contribute to peri-implant health, probably ensuring a more resistant peri-implant mucosal seal (Sanz et al., 2022), associated with lower biofilm accumulation, soft-tissue inflammation, mucosal recession, and MBL (Giannobile et al., 2018; Ramanauskaitė et al., 2022). This hypothesis should be verified in future studies involving soft tissue augmentation procedures performed with a preventive intent towards PIDs and should also specifically assess the benefits/harms ratio taking into account the invasiveness of the intervention and the expected benefits (risk reduction), which to date cannot be evaluated.

### 4.1.5 | Impact of oral hygiene behaviours

Very few studies investigated the impact of different oral health (OH) behaviours on peri-implant health and diseases. The three studies included were inconclusive about the type of toothbrush to use (e.g., powered or manual) or the frequency of toothbrushing that is most effective on peri-implant health. Further studies are awaited because OH remains the key factor to avoid plaque accumulation and peri-implant tissue inflammation (Fu & Wang, 2020). Specific and personalized OH instructions should be given to patients prior to implant placement, and then reviewed at each therapeutic step and when the final implant-supported restoration is loaded, to ensure adequate cleanliness of the prosthetic rehabilitation. This is a complex and difficult task for patients, requiring time, dexterity, and motivation.

## 4.2 | Methodological considerations and study limitations

As mentioned previously, no direct evidence was found assessing the efficacy of primordial and primary preventive interventions for PIDs. This represents the main limitation of the present systematic review and meta-analyses, whose findings are mainly derived from observational studies comparing exposed versus non-exposed groups of patients or two types of intervention not originally delivered to prevent PIDs. Thus, caution should be taken in the critical appraisal of

the results, particularly because we are mostly dealing with indirect evidence, heterogenous studies (in terms of design and working hypothesis), and almost 58% of included studies presented with moderate to high risk of bias. Moreover, only 33% of the studies declared whether funding was received or not, which may also represent a source of bias. Finally, most of the results were reported at the dental implant level only. There are many reasons to privilege the patient as a statistical unit. First, there is a philosophical consideration: we treat the patients, not implants. Second, there is a statistical consideration: dental implants are not independent of the teeth and of each other. Third, there is a medical consideration: when dealing with general health, such as glycaemic control or behaviours, such as smoking, the patient is involved.

Regarding primordial prevention, the lack of data is mainly due to a precise definition of what the ideal peri-implant health is. It seems that each author has a personalized prevention programme that best fits the type of study design. Several components should be included in the definition of the ideal peri-implant health that should be reached prior to dental implant placement.

Regarding primary prevention, another limiting factor is the duration of the follow-up, which was highly variable between the studies. In the present systematic review, a follow-up of a minimum of 6 months was set as a selection criterion; this may be a sufficient time lag to detect some signs of peri-implant inflammation but is likely too short to diagnose peri-implantitis. For this reason, most of the studies with a short-term follow-up did not report PID rates or did not observe any case of PIDs. This should be considered when interpreting the present results, knowing that the risk of PIDs may be dependent on the duration of the exposure to the risk factor(s) (e.g., smoking, poorly controlled diabetes, irregular SPC). Very limited data were available specifically on the prevention of peri-implant mucositis, a predictor of peri-implantitis, and various disease case definitions were used. Further, in the selected studies, several different dental implant brands and several different surgical protocols were applied, leading to considerable clinical heterogeneity, which must be taken into account in the critical appraisal of the results.

The biological factors evaluated in the present review were predetermined, based on the available evidence supporting their impact on the peri-implant tissues. It is possible that other unknown factors may have an effect on peri-implant health. PIDs are more likely to exhibit a multifactorial aetiology (Fu & Wang, 2020; Schliephake, 2022), in which several patient-, implant-, and clinician-related risk factors interact and contribute to the development of PIDs. If this model is accepted, the risk factor control should target all modifiable risk factors identified for a specific patient, meaning implementing multiple preventive interventions simultaneously to be effective in maintaining peri-implant health over time.

Finally, for complex diseases such as PIDs, considering that one isolated risk factor cannot cause a disease on its own and that a practitioner treats patients not dental implants, special attention should be paid to the statistical unit of analysis. PIDs should be explored at the patient level, and specific clinical diagnoses of peri-implantitis or
mucositis should be reported on the top of the clinical parameters such as BOP, PPD, and MBL.

## 4.3 | Implications for future research

* Interventional studies targeting specific preventive measures are needed to gather direct evidence on the efficacy of risk factor control for PIDs.

* Studies should be designed with a follow-up period long enough for the outcomes (e.g., PIDs) to occur.

* Analysis should be performed at the dental implant level and at the patient level.

* Promoting healthy behaviours prior to implant placement to avoid risk factor development (primordial prevention) is probably the most effective strategy to avoid implant complications and PIDs in the long term. In this context, an ideal definition of peri-implant health at the patient level is needed in order to provide an adequate tool to explore primordial prevention in future research.

* The efficacy of preventive measures should be also assessed in specific subsets of patients (e.g., elderly patients, those with comorbidities), in order to assist clinicians in performing personalized medicine.

## 4.4 | Implications for clinical practice

Based on the biological risk factors reviewed in the present article, in patients with healthy implants, the following preventive approaches should be implemented:

* Considering the impact of irregular SPC on peri-implant health, and since inadequate information/motivation appears to be the main patient-reported reason for non-adherence to SPC (Amerio et al., 2020), efforts should be made to increase patients' knowledge about the importance of follow-up after implant therapy and also to increase the dental professionals' skills in motivating patients' behavioural changes.

* Preventing interventions may include

* Promotion of glycaemic control in patients with diabetes

* Smoking cessation counselling

* PIKM augmentation procedure, in cases of deficiency in keratinized tissue width around implants (and in absence of surgical contraindications)

* Personalization of OH instructions, accounting for specific patient- and implant-related characteristics.

# 5 | CONCLUSIONS

Within the limitations of this systematic review, the following conclusions can be drawn:

1. Primary prevention of peri-implantitis relies on regular SPC.

2. In diabetes patients receiving dental implants, glycaemic control is essential for primary prevention of peri-implantitis.

3. An increase of PIKM width may contribute to maintaining peri-implant health.

Further studies are needed to evaluate the impact of smoking cessation and oral hygiene behaviors on the primary prevention of PIDs. A definition for the ideal peri-implant health (at the patient level) is critical to explore primordial prevention. There is an urgent need for standardized primordial and primary prevention protocols for PIDs.

## FUNDING INFORMATION

No external funding, apart from the support of the authors' institution, was available for this study.

## CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

## DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

## ORCID

Maria Clotilde Carra https://orcid.org/0000-0002-5717-3274

Nicolas Blanc-Sylvestre https://orcid.org/0000-0002-0559-1837

Alexandre Courtet https://orcid.org/0000-0001-7634-0878

Philippe Bouchard https://orcid.org/0000-0003-2500-3219

## REFERENCES

Abduljabbar, T., Al-Sahaly, F., Al-Kathami, M., Afzal, S., & Vohra, F. (2017). Comparison of periodontal and peri-implant inflammatory parameters among patients with prediabetes, type 2 diabetes mellitus and non-diabetic controls. *Acta Odontologica Scandinavica*, 75, 319–324. https://doi.org/10.1080/00016357.2017.1303848

Aguilar-Salvatierra, A., Calvo-Guirado, J. L., Gonzalez-Jaranay, M., Moreu, G., Delgado-Ruiz, R. A., & Gomez-Moreno, G. (2016). Peri-implant evaluation of immediately loaded implants placed in esthetic zone in patients with diabetes mellitus type 2: A two-year study. *Clinical Oral Implants Research*, 27, 156–161. https://doi.org/10.1111/clr.12552

Aguirre-Zorzano, L. A., Vallejo-Aisa, F. J., & Estefania-Fresco, R. (2013). Supportive periodontal therapy and periodontal biotype as prognostic factors in implants placed in patients with a history of periodontitis. *Medicina Oral, Patologia Oral y Cirugia Bucal*, 18, e786–e792. https://doi.org/10.4317/medoral.19136

Al Amri, M. D., Kellesarian, S. V., Al-Kheraif, A. A., Malmstrom, H., Javed, F., & Romanos, G. E. (2016). Effect of oral hygiene maintenance on HbA1c levels and peri-implant parameters around immediately-loaded dental implants placed in type-2 diabetic patients: 2 years follow-up. *Clinical Oral Implants Research*, 27, 1439–1443. https://doi.org/10.1111/clr.12758

Al Zahrani, S., & Al Mutairi, A. A. (2019). Crestal bone loss around sub-merged and non-submerged dental implants in individuals with type-2 diabetes mellitus: A 7-year prospective clinical study. *Medical Principles and Practice*, 28, 75–81. https://doi.org/10.1159/000495111

Alhakeem, M., Kanounisabet, N., Nowzari, H., Aslroosta, H., & Moslemi, N. (2022). Risk indicators of long-term outcome of implant therapy in patients with a history of severe periodontitis or no history of
mucositis should be reported on the top of the clinical parameters such as BOP, PPD, and MBL.

## 4.3 | Implications for future research

* Interventional studies targeting specific preventive measures are needed to gather direct evidence on the efficacy of risk factor control for PIDs.

* Studies should be designed with a follow-up period long enough for the outcomes (e.g., PIDs) to occur.

* Analysis should be performed at the dental implant level and at the patient level.

* Promoting healthy behaviours prior to implant placement to avoid risk factor development (primordial prevention) is probably the most effective strategy to avoid implant complications and PIDs in the long term. In this context, an ideal definition of peri-implant health at the patient level is needed in order to provide an adequate tool to explore primordial prevention in future research.

* The efficacy of preventive measures should be also assessed in specific subsets of patients (e.g., elderly patients, those with comorbidities), in order to assist clinicians in performing personalized medicine.

## 4.4 | Implications for clinical practice

Based on the biological risk factors reviewed in the present article, in patients with healthy implants, the following preventive approaches should be implemented:

* Considering the impact of irregular SPC on peri-implant health, and since inadequate information/motivation appears to be the main patient-reported reason for non-adherence to SPC (Amerio et al., 2020), efforts should be made to increase patients' knowledge about the importance of follow-up after implant therapy and also to increase the dental professionals' skills in motivating patients' behavioural changes.

* Preventing interventions may include

* Promotion of glycaemic control in patients with diabetes

* Smoking cessation counselling

* PIKM augmentation procedure, in cases of deficiency in keratinized tissue width around implants (and in absence of surgical contraindications)

* Personalization of OH instructions, accounting for specific patient- and implant-related characteristics.

## 5 | CONCLUSIONS

Within the limitations of this systematic review, the following conclusions can be drawn:

1. Primary prevention of peri-implantitis relies on regular SPC.

2. In diabetes patients receiving dental implants, glycaemic control is essential for primary prevention of peri-implantitis.

3. An increase of PIKM width may contribute to maintaining peri-implant health.

Further studies are needed to evaluate the impact of smoking cessation and oral hygiene behaviors on the primary prevention of PIDs. A definition for the ideal peri-implant health (at the patient level) is critical to explore primordial prevention. There is an urgent need for standardized primordial and primary prevention protocols for PIDs.

### FUNDING INFORMATION

No external funding, apart from the support of the authors' institution, was available for this study.

### CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

### DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

### ORCID

Maria Clotilde Carra https://orcid.org/0000-0002-5717-3274

Nicolas Blanc-Sylvestre https://orcid.org/0000-0002-0559-1837

Alexandre Courtet https://orcid.org/0000-0001-7634-0878

Philippe Bouchard https://orcid.org/0000-0003-2500-3219

### REFERENCES

Abduljabbar, T., Al-Sahaly, F., Al-Kathami, M., Afzal, S., & Vohra, F. (2017). Comparison of periodontal and peri-implant inflammatory parameters among patients with prediabetes, type 2 diabetes mellitus and non-diabetic controls. *Acta Odontologica Scandinavica*, 75, 319–324. https://doi.org/10.1080/00016357.2017.1303848

Aguilar-Salvatierra, A., Calvo-Guirado, J. L., Gonzalez-Jaranay, M., Moreu, G., Delgado-Ruiz, R. A., & Gomez-Moreno, G. (2016). Peri-implant evaluation of immediately loaded implants placed in esthetic zone in patients with diabetes mellitus type 2: A two-year study. *Clinical Oral Implants Research*, 27, 156–161. https://doi.org/10.1111/clr.12552

Aguirre-Zorzano, L. A., Vallejo-Aisa, F. J., & Estefania-Fresco, R. (2013). Supportive periodontal therapy and periodontal biotype as prognostic factors in implants placed in patients with a history of periodontitis. *Medicina Oral, Patologia Oral y Cirugia Bucal*, 18, e786–e792. https://doi.org/10.4317/medoral.19136

Al Amri, M. D., Kellesarian, S. V., Al-Kheraif, A. A., Malmstrom, H., Javed, F., & Romanos, G. E. (2016). Effect of oral hygiene maintenance on HbA1c levels and peri-implant parameters around immediately-loaded dental implants placed in type-2 diabetic patients: 2 years follow-up. *Clinical Oral Implants Research*, 27, 1439–1443. https://doi.org/10.1111/clr.12758

Al Zahrani, S., & Al Mutairi, A. A. (2019). Crestal bone loss around sub-merged and non-submerged dental implants in individuals with type-2 diabetes mellitus: A 7-year prospective clinical study. *Medical Principles and Practice*, 28, 75–81. https://doi.org/10.1159/000495111

Alhakeem, M., Kanounisabet, N., Nowzari, H., Aslroosta, H., & Moslemi, N. (2022). Risk indicators of long-term outcome of implant therapy in patients with a history of severe periodontitis or no history of
periodontitis: A retrospective cohort study. *International Journal of Dental Hygiene*, 21, 227-237. https://doi.org/10.1111/idh.12587

Alqahtani, F., Alqahtani, M., Albaqawi, A. H., Al-Kheraif, A. A., & Javed, F. (2019). Comparison of cotinine levels in the peri-implant sulcular fluid among cigarette and waterpipe smokers, electronic-cigarette users, and nonsmokers. *Clinical Implant Dentistry and Related Research*, 21, 702-707. https://doi.org/10.1111/cid.12813

AlQAhtani, M. A., Alayad, A. S., Alshihri, A., Correa, F. O. B., & Akram, Z. (2018). Clinical peri-implant parameters and inflammatory cytokine profile among smokers of cigarette, e-cigarette, and waterpipe. *Clinical Implant Dentistry and Related Research*, 20, 1016-1021. https://doi.org/10.1111/cid.12664

Alrabiah, M., Al-Aali, K. A., Al-Sowygh, Z. H., Binmahfooz, A. M., Mokeem, S. A., & Abduljabbar, T. (2018). Association of advanced glycation end products with peri-implant inflammation in prediabetes and type 2 diabetes mellitus patients. *Clinical Implant Dentistry and Related Research*, 20, 535-540. https://doi.org/10.1111/cid.12607

Alsahhaf, A., Alshiddi, I. F., Alshagroud, R. S., Al-Aali, K. A., Vohra, F., & Abduljabbar, T. (2019). Clinical and radiographic indices around narrow diameter implants placed in different glycemic-level patients. *Clinical Implant Dentistry and Related Research*, 21, 621-626. https://doi.org/10.1111/cid.12778

Al-Sowygh, Z. H., Ghani, S. M. A., Sergis, K., Vohra, F., & Akram, Z. (2018). Peri-implant conditions and levels of advanced glycation end products among patients with different glycemic control. *Clinical Implant Dentistry and Related Research*, 20, 345-351. https://doi.org/10.1111/cid.12584

Amerio, E., Mainas, G., Petrova, D., Giner Tarrida, L., Nart, J., & Monje, A. (2020). Compliance with supportive periodontal/peri-implant therapy: A systematic review. *Journal of Clinical Periodontology*, 47, 81-100. https://doi.org/10.1111/jcpe.13204

ArRejaie, A. S., Al-Aali, K. A., Alrabiah, M., Vohra, F., Mokeem, S. A., Basunbul, G., Alrahlah, A., & Abduljabbar, T. (2019). Proinflammatory cytokine levels and peri-implant parameters among cigarette smokers, individuals vaping electronic cigarettes, and non-smokers. *Journal of Periodontology*, 90, 367-374. https://doi.org/10.1002/jper.18-0045

Basemez, C., Karabuda, Z. C., Demirel, K., & Yalcin, S. (2013). The comparison of acellular dermal matrix allografts with free gingival grafts in the augmentation of peri-implant attached mucosa: A randomised controlled trial. *European Journal of Oral Implantology*, 6, 145-152.

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., McAuley, 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 Classification of Periodontal and Peri-Implant Diseases and Conditions. *Journal of Clinical Periodontology*, 45(Suppl 20), S286-S291. https://doi.org/10.1111/jcpe.12957

Bienz, S. P., Jung, R. E., Sapata, V. M., Hammerle, C. H. F., Husler, J., & Thoma, D. S. (2017). Volumetric changes and peri-implant health at implant sites with or without soft tissue grafting in the esthetic zone, a retrospective case-control study with a 5-year follow-up. *Clinical Oral Implants Research*, 28, 1459-1465. https://doi.org/10.1111/clr.13013

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Carra, M. C., Range, H., Swerts, P. J., Tuand, K., Vandamme, K., & Bouchard, P. (2022). Effectiveness of implant-supported fixed partial denture in patients with history of periodontitis: A systematic review and meta-analysis. *Journal of Clinical Periodontology*, 49(Suppl 24), 208-223. https://doi.org/10.1111/jcpe.13481

Carral, C., Flores-Guillen, J., Figuero, E., Rodrigo, D., Sanz-Sanchez, I., Llodra, J. C., Bravo, M., Caffesse, R. G., Vallcorba, N., Guerrero, A., Bujaldón, A., & Herrera, D. (2021). Peri-implant radiographic bone level and associated factors in Spain. *Journal of Clinical Periodontology*, 48, 805-815. https://doi.org/10.1111/jcpe.13437

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Costa, F. O., Lages, E. J. P., Cortelli, S. C., Cortelli, J. R., Mattos-Pereira, G. H., Lima, R. P. E., & Cota, L. O. M. (2022). Association between cumulative smoking exposure, span since smoking cessation, and peri-implantitis: A cross-sectional study. *Clinical Oral Investigations*, 26, 4835-4846. https://doi.org/10.1007/s00784-022-04451-8

Derks, J., Ichioka, Y., Dionigi, C., Trullenque-Eriksson, A., Berglundh, J., Tomasi, C., & Graziani, F. (2022). Prevention and management of peri-implant mucositis and peri-implantitis: A systematic review of outcome measures used in clinical studies in the last 10 years. *Journal of Clinical Periodontology*. Online ahead of print. https://doi.org/10.1111/jcpe.13608

Ferreira, S. D., Silva, G. L., Cortelli, J. R., Costa, J. E., & Costa, F. O. (2006). Prevalence and risk variables for peri-implant disease in Brazilian subjects. *Journal of Clinical Periodontology*, 33, 929-935. https://doi.org/10.1111/j.1600-051X.2006.01001.x

Frisch, E., Vach, K., & Ratka-Krueger, P. (2020). Impact of supportive implant therapy on peri-implant diseases: A retrospective 7-year study. *Journal of Clinical Periodontology*, 47, 101-109. https://doi.org/10.1111/jcpe.13206

Frisch, E., Ziebolz, D., Vach, K., & Ratka-Kruger, P. (2015). The effect of keratinized mucosa width on peri-implant outcome under supportive postimplant therapy. *Clinical Implant Dentistry and Related Research*, 17(Suppl 1), e236-e244. https://doi.org/10.1111/cid.12187

Fu, J. H., & Wang, H. L. (2020). Breaking the wave of peri-implantitis. *Periodontology 2000*, 84(1), 145-160. https://doi.org/10.1111/prd.12335

Genco, R. J., & Borgnakke, W. S. (2020). Diabetes as a potential risk for periodontitis: Association studies. *Periodontology 2000, 2000(83), 40-45. https://doi.org/10.1111/prd.12270

Ghiraldini, B., Conte, A., Casarin, R. C., Casati, M. Z., Pimentel, S. P., Cirano, F. R., & Ribeiro, F. V. (2016). Influence of glycemic control on peri-implant bone healing: 12-month outcomes of local release of bone-related factors and implant stabilization in type 2 diabetics. *Clinical Implant Dentistry and Related Research*, 18, 801-809. https://doi.org/10.1111/cid.12339

Giannobile, W. V., Jung, R. E., & Schwarz, F. (2018). Evidence-based knowledge on the aesthetics and maintenance of peri-implant soft tissues: Osteology Foundation Consensus Report Part 1—Effects of soft
periodontitis: A retrospective cohort study. *International Journal of Dental Hygiene*, 21, 227-237. https://doi.org/10.1111/idh.12587

Alqahtani, F., Alqahtani, M., Albaqawi, A. H., Al-Kheraif, A. A., & Javed, F. (2019). Comparison of cotinine levels in the peri-implant sulcular fluid among cigarette and waterpipe smokers, electronic-cigarette users, and nonsmokers. *Clinical Implant Dentistry and Related Research*, 21, 702-707. https://doi.org/10.1111/cid.12813

AlQAhtani, M. A., Alayad, A. S., Alshihri, A., Correa, F. O. B., & Akram, Z. (2018). Clinical peri-implant parameters and inflammatory cytokine profile among smokers of cigarette, e-cigarette, and waterpipe. *Clinical Implant Dentistry and Related Research*, 20, 1016-1021. https://doi.org/10.1111/cid.12664

Alrabiah, M., Al-Aali, K. A., Al-Sowygh, Z. H., Binmahfooz, A. M., Mokeem, S. A., & Abduljabbar, T. (2018). Association of advanced glycation end products with peri-implant inflammation in prediabetes and type 2 diabetes mellitus patients. *Clinical Implant Dentistry and Related Research*, 20, 535-540. https://doi.org/10.1111/cid.12607

Alsahhaf, A., Alshiddi, I. F., Alshagroud, R. S., Al-Aali, K. A., Vohra, F., & Abduljabbar, T. (2019). Clinical and radiographic indices around narrow diameter implants placed in different glycemic-level patients. *Clinical Implant Dentistry and Related Research*, 21, 621-626. https://doi.org/10.1111/cid.12778

Al-Sowygh, Z. H., Ghani, S. M. A., Sergis, K., Vohra, F., & Akram, Z. (2018). Peri-implant conditions and levels of advanced glycation end products among patients with different glycemic control. *Clinical Implant Dentistry and Related Research*, 20, 345-351. https://doi.org/10.1111/cid.12584

Amerio, E., Mainas, G., Petrova, D., Giner Tarrida, L., Nart, J., & Monje, A. (2020). Compliance with supportive periodontal/peri-implant therapy: A systematic review. *Journal of Clinical Periodontology*, 47, 81-100. https://doi.org/10.1111/jcpe.13204

ArRejaie, A. S., Al-Aali, K. A., Alrabiah, M., Vohra, F., Mokeem, S. A., Basunbul, G., Alrahlah, A., & Abduljabbar, T. (2019). Proinflammatory cytokine levels and peri-implant parameters among cigarette smokers, individuals vaping electronic cigarettes, and non-smokers. *Journal of Periodontology*, 90, 367-374. https://doi.org/10.1002/jper.18-0045

Basemez, C., Karabuda, Z. C., Demirel, K., & Yalcin, S. (2013). The comparison of acellular dermal matrix allografts with free gingival grafts in the augmentation of peri-implant attached mucosa: A randomised controlled trial. *European Journal of Oral Implantology*, 6, 145-152.

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., McAuley, 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 Classification of Periodontal and Peri-Implant Diseases and Conditions. *Journal of Clinical Periodontology*, 45(Suppl 20), S286-S291. https://doi.org/10.1111/jcpe.12957

Bienz, S. P., Jung, R. E., Sapata, V. M., Hammerle, C. H. F., Husler, J., & Thoma, D. S. (2017). Volumetric changes and peri-implant health at implant sites with or without soft tissue grafting in the esthetic zone, a retrospective case-control study with a 5-year follow-up. *Clinical Oral Implants Research*, 28, 1459-1465. https://doi.org/10.1111/clr.13013

Buyukozdemir Askin, S., Berker, E., Akincibay, H., Uysal, S., Erman, B., Tezcan, İ., & Karabulut, E. (2015). Necessity of keratinized tissues for dental implants: A clinical, immunological, and radiographic study. *Clinical Implant Dentistry and Related Research*, 17, 1-12. https://doi.org/10.1111/cid.12079

Cairo, F., Barbato, L., Tonelli, P., Batalocco, G., Pagavino, G., & Nieri, M. (2017). Xenogeneic collagen matrix versus connective tissue graft for buccal soft tissue augmentation at implant site. A randomized, controlled clinical trial. *Journal of Clinical Periodontology*, 44, 769-776. https://doi.org/10.1111/jcpe.12750

Carra, M. C., Range, H., Swerts, P. J., Tuand, K., Vandamme, K., & Bouchard, P. (2022). Effectiveness of implant-supported fixed partial denture in patients with history of periodontitis: A systematic review and meta-analysis. *Journal of Clinical Periodontology*, 49(Suppl 24), 208-223. https://doi.org/10.1111/jcpe.13481

Carral, C., Flores-Guillen, J., Figuero, E., Rodrigo, D., Sanz-Sanchez, I., Llodra, J. C., Bravo, M., Caffesse, R. G., Vallcorba, N., Guerrero, A., Bujaldón, A., & Herrera, D. (2021). Peri-implant radiographic bone level and associated factors in Spain. *Journal of Clinical Periodontology*, 48, 805-815. https://doi.org/10.1111/jcpe.13437

Caton, J. G., Armitage, G., Berglundh, T., Chapple, I. L. C., Jepsen, S., Kornman, K. S., Mealey, B. L., Papapanou, P. N., Sanz, M., & Tonetti, M. S. (2018). A new classification scheme for periodontal and peri-implant diseases and conditions - Introduction and key changes from the 1999 classification. *Journal of Clinical Periodontology*, 45(Suppl 20), S1-s8. https://doi.org/10.1111/jcpe.12935

Chambrone, L., & Palma, L. F. (2019). Current status of dental implants survival and peri-implant bone loss in patients with uncontrolled type-2 diabetes mellitus. *Current Opinion in Endocrinology, Diabetes, and Obesity*, 26, 219-222. https://doi.org/10.1097/MED.0000000000000482

Cho-Yan Lee, J., Mattheos, N., Nixon, K. C., & Ivanovski, S. (2012). Residual periodontal pockets are a risk indicator for peri-implantitis in patients treated for periodontitis. *Clinical Oral Implants Research*, 23, 325-333. https://doi.org/10.1111/j.1600-0501.2011.02264.x

Cortellini, S., Favril, C., De Nutte, M., Teughels, W., & Quirynen, M. (2019). Patient compliance as a risk factor for the outcome of implant treatment. *Periodontology 2000, 2000(81), 209-225. https://doi.org/10.1111/prd.12293

Costa, F. O., Lages, E. J. P., Cortelli, S. C., Cortelli, J. R., Mattos-Pereira, G. H., Lima, R. P. E., & Cota, L. O. M. (2022). Association between cumulative smoking exposure, span since smoking cessation, and peri-implantitis: A cross-sectional study. *Clinical Oral Investigations*, 26, 4835-4846. https://doi.org/10.1007/s00784-022-04451-8

Derks, J., Ichioka, Y., Dionigi, C., Trullenque-Eriksson, A., Berglundh, J., Tomasi, C., & Graziani, F. (2022). Prevention and management of peri-implant mucositis and peri-implantitis: A systematic review of outcome measures used in clinical studies in the last 10 years. *Journal of Clinical Periodontology*. Online ahead of print. https://doi.org/10.1111/jcpe.13608

Ferreira, S. D., Silva, G. L., Cortelli, J. R., Costa, J. E., & Costa, F. O. (2006). Prevalence and risk variables for peri-implant disease in Brazilian subjects. *Journal of Clinical Periodontology*, 33, 929-935. https://doi.org/10.1111/j.1600-051X.2006.01001.x

Frisch, E., Vach, K., & Ratka-Krueger, P. (2020). Impact of supportive implant therapy on peri-implant diseases: A retrospective 7-year study. *Journal of Clinical Periodontology*, 47, 101-109. https://doi.org/10.1111/jcpe.13206

Frisch, E., Ziebolz, D., Vach, K., & Ratka-Kruger, P. (2015). The effect of keratinized mucosa width on peri-implant outcome under supportive postimplant therapy. *Clinical Implant Dentistry and Related Research*, 17(Suppl 1), e236-e244. https://doi.org/10.1111/cid.12187

Fu, J. H., & Wang, H. L. (2020). Breaking the wave of peri-implantitis. *Periodontology 2000*, 84(1), 145-160. https://doi.org/10.1111/prd.12335

Genco, R. J., & Borgnakke, W. S. (2020). Diabetes as a potential risk for periodontitis: Association studies. *Periodontology 2000, 2000(83), 40-45. https://doi.org/10.1111/prd.12270

Ghiraldini, B., Conte, A., Casarin, R. C., Casati, M. Z., Pimentel, S. P., Cirano, F. R., & Ribeiro, F. V. (2016). Influence of glycemic control on peri-implant bone healing: 12-month outcomes of local release of bone-related factors and implant stabilization in type 2 diabetics. *Clinical Implant Dentistry and Related Research*, 18, 801-809. https://doi.org/10.1111/cid.12339

Giannobile, W. V., Jung, R. E., & Schwarz, F. (2018). Evidence-based knowledge on the aesthetics and maintenance of peri-implant soft tissues: Osteology Foundation Consensus Report Part 1—Effects of soft
tissue augmentation procedures on the maintenance of peri-implant soft tissue health. *Clinical Oral Implants Research*, 29(Suppl 15), 7-10. https://doi.org/10.1111/clr.13110

Gomez-Moreno, G., Aguilar-Salvatierra, A., Rubio Roldan, J., Guardia, J., Gargallo, J., & Calvo-Guirado, J. L. (2015). Peri-implant evaluation in type 2 diabetes mellitus patients: A 3-year study. *Clinical Oral Implants Research*, 26, 1031-1035. https://doi.org/10.1111/clr.12391

Gurgel, B. C. V., Montenegro, S. C. L., Dantas, P. M. C., Pascoal, A. L. B., Lima, K. C., & Calderon, P. D. S. (2017). Frequency of peri-implant diseases and associated factors. *Clinical Oral Implants Research*, 28, 1211-1217. https://doi.org/10.1111/clr.12944

Herrera, D., Sanz, M., Kebschull, M., Jepsen, S., Sculean, A., Berglundh, T., Papapanou, P. N., Chapple, I., Tonetti, M. S., & EFP Workshop Participants and Methodological Consultant. (2022). Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. *Journal of Clinical Periodontology*, 49(Suppl 24), 4-71. https://doi.org/10.1111/jcpe.13639

Higgins, J. P. T., Sterne, J. A. C., Savović, J., Page, M. J., Hróbjartsson, A., Boutron, I., ... Eldridge, S. (2016). A revised tool for assessing risk of bias in randomized trials. In J. Chandler, J. McKenzie, I. Boutron, & V. Welch (Eds.), *Cochrane database of systematic reviews* (Vol. 10) (Suppl 1, pp. 29-31). Cochrane.

Holliday, R., Hong, B., McColl, E., Livingstone-Banks, J., & Preshaw, P. M. (2021). Interventions for tobacco cessation delivered by dental professionals. *Cochrane Database of Systematic Reviews*, 2, Cd005084. https://doi.org/10.1002/14651858.CD005084.pub4

Hosseini, M., Worsaae, N., & Gotfredsen, K. (2020). Tissue changes at implant sites in the anterior maxilla with and without connective tissue grafting: A five-year prospective study. *Clinical Oral Implants Research*, 31, 18-28. https://doi.org/10.1111/clr.13540

Hu, C., Lang, N. P., Ong, M. M., Lim, L. P., & Tan, W. C. (2020). Influence of periodontal maintenance and periodontitis susceptibility on implant success: A 5-year retrospective cohort on moderately rough surfaced implants. *Clinical Oral Implants Research*, 31, 727-736. https://doi.org/10.1111/clr.13621

Huang, J. P., Liu, J. M., Wu, Y. M., Dai, A., Hu, H. J., He, F. M., Chen, Q.-M., Li, X.-J., Sun, P., & Ding, P. H. (2021). Clinical evaluation of xenogeneic collagen matrix versus free gingival grafts for keratinized mucosa augmentation around dental implants: A randomized controlled clinical trial. *Journal of Clinical Periodontology*, 48, 1293-1301. https://doi.org/10.1111/jcpe.13518

Javed, F., Rahman, I., & Romanos, G. E. (2019). Tobacco-product usage as a risk factor for dental implants. *Periodontology 2000*, 2000(81), 48-56. https://doi.org/10.1111/prd.12282

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., & Zitzmann, N. U. (2015). Primary prevention of peri-implantitis: Managing peri-implant mucositis. *Journal of Clinical Periodontology*, 42(Suppl 16), S152-S157. https://doi.org/10.1111/jcpe.12369

Jiang, X., Zhu, Y., Liu, Z., Tian, Z., & Zhu, S. (2021). Association between diabetes and dental implant complications: A systematic review and meta-analysis. *Acta Odontologica Scandinavica*, 79, 9-18. https://doi.org/10.1080/00016357.2020.1761031

Kikuchi, T., Wada, M., Mameno, T., Hasegawa, D., Serino, G., & Ikebe, K. (2022). Longitudinal study on the effect of keratinized mucosal augmentation surrounding dental implants in preventing peri-implant bone loss. *PeerJ*. 10, e13598. https://doi.org/10.7717/peerj.13598

Kisling, L. A., & Das, M. J. (2022). *Prevention strategies*. https://www.ncbi.nlm.nih.gov/books/NBK537222/.

Koutouzis, T. (2019). Implant-abutment connection as contributing factor to peri-implant diseases. *Periodontology 2000*, 2000(81), 152-166. https://doi.org/10.1111/prd.12289

Linkevicius, T., Puisys, A., Linkeviciene, L., Peciuliene, V., & Schlee, M. (2015). Crestal bone stability around implants with horizontally matching connection after soft tissue thickening: A prospective clinical trial. *Clinical Implant Dentistry and Related Research*, 17, 497-508. https://doi.org/10.1111/cid.12155

Loos, B. G., Papantonopoulos, G., Jepsen, S., & Laine, M. L. (2015). What is the contribution of genetics to periodontal risk? *Dental Clinics of North America*, 59, 761-780. https://doi.org/10.1016/j.cden.2015.06.005

Loos, B. G., & Van Dyke, T. E. (2020). The role of inflammation and genetics in periodontal disease. *Periodontology 2000*, 2000(83), 26-39. https://doi.org/10.1111/prd.12297

Lorenzo, R., Garcia, V., Orsini, M., Martin, C., & Sanz, M. (2012). Clinical efficacy of a xenogeneic collagen matrix in augmenting keratinized mucosa around implants: A randomized controlled prospective clinical trial. *Clinical Oral Implants Research*, 23, 316-324. https://doi.org/10.1111/j.1600-0501.2011.02260.x

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, P. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. *PLoS Medicine*, 6, e1000097. https://doi.org/10.1371/journal.pmed.1000097

Mokeem, S., Alfadda, S. A., Al-Shibani, N., Alrabiah, M., Al-Hamdan, R. S., Vohra, F., & Abduljabbar, T. (2019). Clinical and radiographic peri-implant variables around short dental implants in type 2 diabetic, pre-diabetic, and non-diabetic patients. *Clinical Implant Dentistry and Related Research*, 21, 60-65. https://doi.org/10.1111/cid.12691

Monje, A., Wang, H. L., & Nart, J. (2017). Association of preventive maintenance therapy compliance and peri-implant diseases: A cross-sectional study. *Journal of Periodontology*, 88, 1030-1041. https://doi.org/10.1902/jop.2017.170135

Oh, S. L., Ji, C., & Azad, S. (2020). Free gingival grafts for implants exhibiting a lack of keratinized mucosa: Extended follow-up of a randomized controlled trial. *Journal of Clinical Periodontology*, 47, 777-785. https://doi.org/10.1111/jcpe.13272

Oh, S. L., Masri, R. M., Williams, D. A., Ji, C., & Romberg, E. (2017). Free gingival grafts for implants exhibiting lack of keratinized mucosa: A prospective controlled randomized clinical study. *Journal of Clinical Periodontology*, 44, 195-203. https://doi.org/10.1111/jcpe.12660

Popelut, A., Valet, F., Fromentin, O., Thomas, A., & Bouchard, P. (2010). Relationship between sponsorship and failure rate of dental implants: A systematic approach. *PLoS One*, 5, e10274. https://doi.org/10.1371/journal.pone.0010274

Ramanauskaite, A., Schwarz, F., & Sader, R. (2022). Influence of width of keratinized tissue on the prevalence of peri-implant diseases: A systematic review and meta-analysis. *Clinical Oral Implants Research*, 33(Suppl 23), 8-31. https://doi.org/10.1111/clr.13766

Renvert, S., Persson, G. R., Pirih, F. Q., & Camargo, P. M. (2018). Peri-implant health, peri-implant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. *Journal of Clinical Periodontology*, 45(Suppl 20), S278-S285. https://doi.org/10.1111/jcpe.12956

Renvert, S., & Quirynen, M. (2015). Risk indicators for peri-implantitis. A narrative review. *Clinical Oral Implants Research*, 26(Suppl 11), 15-44. https://doi.org/10.1111/clr.12636

Rinke, S., Nordlohne, M., Leha, A., Renvert, S., Schmalz, G., & Ziebolz, D. (2020). Risk indicators for mucositis and peri-implantitis: Results from a practice-based cross-sectional study. *Journal of Periodontal & Implant Science*, 50, 183-196. https://doi.org/10.5051/jpis.2020.50.3.183

Rinke, S., Ohl, S., Ziebolz, D., Lange, K., & Eickholz, P. (2011). Prevalence of periimplant disease in partially edentulous patients: A practice-based cross-sectional study. *Clinical Oral Implants Research*, 22, 826-833. https://doi.org/10.1111/j.1600-0501.2010.02061.x

Roccuzzo, A., Imber, J. C., Marruganti, C., Salvi, G. E., Ramieri, G., & Roccuzzo, M. (2022). Clinical outcomes of dental implants in patients with and without history of periodontitis: A 20-year prospective study.
tissue augmentation procedures on the maintenance of peri-implant soft tissue health. *Clinical Oral Implants Research*, 29(Suppl 15), 7-10. https://doi.org/10.1111/clr.13110

Gomez-Moreno, G., Aguilar-Salvatierra, A., Rubio Roldan, J., Guardia, J., Gargallo, J., & Calvo-Guirado, J. L. (2015). Peri-implant evaluation in type 2 diabetes mellitus patients: A 3-year study. *Clinical Oral Implants Research*, 26, 1031-1035. https://doi.org/10.1111/clr.12391

Gurgel, B. C. V., Montenegro, S. C. L., Dantas, P. M. C., Pascoal, A. L. B., Lima, K. C., & Calderon, P. D. S. (2017). Frequency of peri-implant diseases and associated factors. *Clinical Oral Implants Research*, 28, 1211-1217. https://doi.org/10.1111/clr.12944

Herrera, D., Sanz, M., Kebschull, M., Jepsen, S., Sculean, A., Berglundh, T., Papapanou, P. N., Chapple, I., Tonetti, M. S., & EFP Workshop Participants and Methodological Consultant. (2022). Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. *Journal of Clinical Periodontology*, 49(Suppl 24), 4-71. https://doi.org/10.1111/jcpe.13639

Higgins, J. P. T., Sterne, J. A. C., Savović, J., Page, M. J., Hróbjartsson, A., Boutron, I., ... Eldridge, S. (2016). A revised tool for assessing risk of bias in randomized trials. In J. Chandler, J. McKenzie, I. Boutron, & V. Welch (Eds.), *Cochrane database of systematic reviews* (Vol. 10) (Suppl 1, pp. 29-31). Cochrane.

Holliday, R., Hong, B., McColl, E., Livingstone-Banks, J., & Preshaw, P. M. (2021). Interventions for tobacco cessation delivered by dental professionals. *Cochrane Database of Systematic Reviews*, 2, Cd005084. https://doi.org/10.1002/14651858.CD005084.pub4

Hosseini, M., Worsaae, N., & Gotfredsen, K. (2020). Tissue changes at implant sites in the anterior maxilla with and without connective tissue grafting: A five-year prospective study. *Clinical Oral Implants Research*, 31, 18-28. https://doi.org/10.1111/clr.13540

Hu, C., Lang, N. P., Ong, M. M., Lim, L. P., & Tan, W. C. (2020). Influence of periodontal maintenance and periodontitis susceptibility on implant success: A 5-year retrospective cohort on moderately rough surfaced implants. *Clinical Oral Implants Research*, 31, 727-736. https://doi.org/10.1111/clr.13621

Huang, J. P., Liu, J. M., Wu, Y. M., Dai, A., Hu, H. J., He, F. M., Chen, Q.-M., Li, X.-J., Sun, P., & Ding, P. H. (2021). Clinical evaluation of xenogeneic collagen matrix versus free gingival grafts for keratinized mucosa augmentation around dental implants: A randomized controlled clinical trial. *Journal of Clinical Periodontology*, 48, 1293-1301. https://doi.org/10.1111/jcpe.13518

Javed, F., Rahman, I., & Romanos, G. E. (2019). Tobacco-product usage as a risk factor for dental implants. *Periodontology 2000*, 2000(81), 48-56. https://doi.org/10.1111/prd.12282

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., & Zitzmann, N. U. (2015). Primary prevention of peri-implantitis: Managing peri-implant mucositis. *Journal of Clinical Periodontology*, 42(Suppl 16), S152-S157. https://doi.org/10.1111/jcpe.12369

Jiang, X., Zhu, Y., Liu, Z., Tian, Z., & Zhu, S. (2021). Association between diabetes and dental implant complications: A systematic review and meta-analysis. *Acta Odontologica Scandinavica*, 79, 9-18. https://doi.org/10.1080/00016357.2020.1761031

Kikuchi, T., Wada, M., Mameno, T., Hasegawa, D., Serino, G., & Ikebe, K. (2022). Longitudinal study on the effect of keratinized mucosal augmentation surrounding dental implants in preventing peri-implant bone loss. *PeerJ*. 10, e13598. https://doi.org/10.7717/peerj.13598

Kisling, L. A., & Das, M. J. (2022). *Prevention strategies*. https://www.ncbi.nlm.nih.gov/books/NBK537222/.

Koutouzis, T. (2019). Implant-abutment connection as contributing factor to peri-implant diseases. *Periodontology 2000*, 2000(81), 152-166. https://doi.org/10.1111/prd.12289

Linkevicius, T., Puisys, A., Linkeviciene, L., Peciuliene, V., & Schlee, M. (2015). Crestal bone stability around implants with horizontally matching connection after soft tissue thickening: A prospective clinical trial. *Clinical Implant Dentistry and Related Research*, 17, 497-508. https://doi.org/10.1111/cid.12155

Loos, B. G., Papantonopoulos, G., Jepsen, S., & Laine, M. L. (2015). What is the contribution of genetics to periodontal risk? *Dental Clinics of North America*, 59, 761-780. https://doi.org/10.1016/j.cden.2015.06.005

Loos, B. G., & Van Dyke, T. E. (2020). The role of inflammation and genetics in periodontal disease. *Periodontology 2000*, 2000(83), 26-39. https://doi.org/10.1111/prd.12297

Lorenzo, R., Garcia, V., Orsini, M., Martin, C., & Sanz, M. (2012). Clinical efficacy of a xenogeneic collagen matrix in augmenting keratinized mucosa around implants: A randomized controlled prospective clinical trial. *Clinical Oral Implants Research*, 23, 316-324. https://doi.org/10.1111/j.1600-0501.2011.02260.x

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, P. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. *PLoS Medicine*, 6, e1000097. https://doi.org/10.1371/journal.pmed.1000097

Mokeem, S., Alfadda, S. A., Al-Shibani, N., Alrabiah, M., Al-Hamdan, R. S., Vohra, F., & Abduljabbar, T. (2019). Clinical and radiographic peri-implant variables around short dental implants in type 2 diabetic, pre-diabetic, and non-diabetic patients. *Clinical Implant Dentistry and Related Research*, 21, 60-65. https://doi.org/10.1111/cid.12691

Monje, A., Wang, H. L., & Nart, J. (2017). Association of preventive maintenance therapy compliance and peri-implant diseases: A cross-sectional study. *Journal of Periodontology*, 88, 1030-1041. https://doi.org/10.1902/jop.2017.170135

Oh, S. L., Ji, C., & Azad, S. (2020). Free gingival grafts for implants exhibiting a lack of keratinized mucosa: Extended follow-up of a randomized controlled trial. *Journal of Clinical Periodontology*, 47, 777-785. https://doi.org/10.1111/jcpe.13272

Oh, S. L., Masri, R. M., Williams, D. A., Ji, C., & Romberg, E. (2017). Free gingival grafts for implants exhibiting lack of keratinized mucosa: A prospective controlled randomized clinical study. *Journal of Clinical Periodontology*, 44, 195-203. https://doi.org/10.1111/jcpe.12660

Popelut, A., Valet, F., Fromentin, O., Thomas, A., & Bouchard, P. (2010). Relationship between sponsorship and failure rate of dental implants: A systematic approach. *PLoS One*, 5, e10274. https://doi.org/10.1371/journal.pone.0010274

Ramanauskaite, A., Schwarz, F., & Sader, R. (2022). Influence of width of keratinized tissue on the prevalence of peri-implant diseases: A systematic review and meta-analysis. *Clinical Oral Implants Research*, 33(Suppl 23), 8-31. https://doi.org/10.1111/clr.13766

Renvert, S., Persson, G. R., Pirih, F. Q., & Camargo, P. M. (2018). Peri-implant health, peri-implant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. *Journal of Clinical Periodontology*, 45(Suppl 20), S278-S285. https://doi.org/10.1111/jcpe.12956

Renvert, S., & Quirynen, M. (2015). Risk indicators for peri-implantitis. A narrative review. *Clinical Oral Implants Research*, 26(Suppl 11), 15-44. https://doi.org/10.1111/clr.12636

Rinke, S., Nordlohne, M., Leha, A., Renvert, S., Schmalz, G., & Ziebolz, D. (2020). Risk indicators for mucositis and peri-implantitis: Results from a practice-based cross-sectional study. *Journal of Periodontal & Implant Science*, 50, 183-196. https://doi.org/10.5051/jpis.2020.50.3.183

Rinke, S., Ohl, S., Ziebolz, D., Lange, K., & Eickholz, P. (2011). Prevalence of periimplant disease in partially edentulous patients: A practice-based cross-sectional study. *Clinical Oral Implants Research*, 22, 826-833. https://doi.org/10.1111/j.1600-0501.2010.02061.x

Roccuzzo, A., Imber, J. C., Marruganti, C., Salvi, G. E., Ramieri, G., & Roccuzzo, M. (2022). Clinical outcomes of dental implants in patients with and without history of periodontitis: A 20-year prospective study.
Journal of Clinical Periodontology, 49, 1346-1356. https://doi.org/10.1111/jcpe.13716

Roccuzzo, M., Bonino, F., Aglietta, M., & Dalmasso, P. (2012). Ten-year results of a three arms prospective cohort study on implants in peri-odontally compromised patients. Part 2: Clinical results. *Clinical Oral Implants Research*, 23, 389-395. https://doi.org/10.1111/j.1600-0501.2011.02309.x

Roccuzzo, M., Bonino, L., Dalmasso, P., & Aglietta, M. (2014). Long-term results of a three arms prospective cohort study on implants in peri-odontally compromised patients: 10-year data around sandblasted and acid-etched (SLA) surface. *Clinical Oral Implants Research*, 25, 1105-1112. https://doi.org/10.1111/clr.12227

Roccuzzo, M., De Angelis, N., Bonino, L., & Aglietta, M. (2010). Ten-year results of a three-arm prospective cohort study on implants in peri-odontally compromised patients. Part 1: Implant loss and radiographic bone loss. *Clinical Oral Implants Research*, 21, 490-496. https://doi.org/10.1111/j.1600-0501.2009.01886.x

Roccuzzo, M., Grasso, G., & Dalmasso, P. (2016). Keratinized mucosa around implants in partially edentulous posterior mandible: 10-year results of a prospective comparative study. *Clinical Oral Implants Research*, 27, 491-496. https://doi.org/10.1111/clr.12563

Roman-Torres, C. V. G., Pasquinelli, F., Pimentel, A. C., de Melo, M. P., Rego, R. O., & Sendyk, W. R. (2019). The effects of annual maintenance on peri-implant health in patients rehabilitated with overdentures: A retrospective cohort study. *The International Journal of Oral & Maxillofacial Implants*, 34, 159-164. https://doi.org/10.11607/jomi.6815

Salvi, G. E., Aglietta, M., Eick, S., Sculean, A., Lang, N. P., & Ramseier, C. A. (2012). Reversibility of experimental peri-implant mucositis compared with experimental gingivitis in humans. *Clinical Oral Implants Research*, 23, 182-190. https://doi.org/10.1111/j.1600-0501.2011.02220.x

Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Beglundh, T., Sculean, A., Tonetti, M. S., EFP Workshop Participants and Methodological Consultants, Merete Aass, A., & Aimetti, M. (2020). Treatment of stage I-III periodontitis—The EFP S3 level clinical practice guideline. *Journal of Clinical Periodontology*, 47(Suppl 22), 4-60. https://doi.org/10.1111/jcpe.13290

Sanz, M., Schwarz, F., Herrera, D., McClain, P., Figuero, E., Molina, A., Montero, E., Pascual, A., Ramanauskaitė, A., Renouard, F., Sader, R., Schiegnitz, E., Urban, I., & Heitz-Mayfield, L. (2022). Importance of keratinized mucosa around dental implants: Consensus report of group 1 of the DGI/SEPA/Osteology Workshop. *Clinical Oral Implants Research*, 33(Suppl 23), 47-55. https://doi.org/10.1111/clr.13956

Schliephake, H. (2022). The role of systemic diseases and local conditions as risk factors. *Periodontology 2000, 2000(88), 36-51. https://doi.org/10.1111/prd.12409

Schwarz, F., Alcoforado, G., Guerrero, A., Jonsson, D., Klinge, B., Lang, N., Mattheos, N., Mertens, B., Pitta, J., Ramanauskaitė, A., Sayardoust, S., Sanz-Martin, I., Stavropoulos, A., & Heitz-Mayfield, L. (2021). Peri-implantitis: Summary and consensus statements of group 3. The 6th EAO Consensus Conference 2021. *Clinical Oral Implants Research*, 32-(Suppl 21), 245-253. https://doi.org/10.1111/clr.13827

Schwarz, F., Derks, J., Monje, A., & Wang, H. L. (2018). Peri-implantitis. *Journal of Periodontology*, 89(Suppl 1), S267-S290. https://doi.org/10.1002/JPER.16-0350

Stang, A. (2010). Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. *European Journal of Epidemiology*, 25, 603-605. https://doi.org/10.1007/s10654-010-9491-z

Staubli, N., Walter, C., Schmidt, J. C., Weiger, R., & Zitzmann, N. U. (2017). Excess cement and the risk of peri-implant disease—a systematic review. *Clinical Oral Implants Research*, 28, 1278-1290. https://doi.org/10.1111/clr.12954

Sterne, J. A., Hernan, M. A., Reeves, B. C., Savovic, J., Berkman, N. D., Viswanathan, M., Henry, D., Altman, D. G., Ansari, M. T., Boutron, I., Carpenter, J. R., Chan, A.-W., Churchill, R., Deeks, J. J., Hróbjartsson, A., Kirkham, J., Jüni, P., Loke, Y. K., Pigott, T. D., ... Higgins, J. P. (2016). ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions. *BMJ*, 355, i4919. https://doi.org/10.1136/bmj.i4919

Swierkot, K., Brusius, M., Leismann, D., Nonnenmacher, C., Nusing, R., Lubbe, D., Schade-Brittinger, C., & Mengel, R. (2013). Manual versus sonic-powered toothbrushing for plaque reduction in patients with dental implants: An explanatory randomised controlled trial. *European Journal of Oral Implantology*, 6, 133-144.

Tawil, G., Younan, R., Azar, P., & Sleilati, G. (2008). Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long-term clinical results. *The International Journal of Oral & Maxillofacial Implants*, 23, 744-752.

Thoma, D. S., Cosyn, J., Fickl, S., Jensen, S. S., Jung, R. E., Raghoebar, G. M., Rocchietta, I., Roccuzzo, M., Sanz, M., Sanz-Sánchez, I., Scarlat, P., Schou, S., Stefanini, M., Strasding, M., Bertl, K., Working Group 2 of the 6th EAO Consensus Conference 2021, & Bertl, K. (2021). Soft tissue management at implants: Summary and consensus statements of group 2. The 6th EAO Consensus Conference 2021. *Clinical Oral Implants Research*, 32(Suppl 21), 174-180. https://doi.org/10.1111/clr.13798

Thoma, D. S., Gasser, T. J. W., Hammerle, C. H. F., Strauss, F. J., & Jung, R. E. (2023). Soft tissue augmentation with a volume-stable collagen matrix or an autogenous connective tissue graft at implant sites: 5-year results of a randomized controlled trial post implant loading. *Journal of Periodontology*, 94(2), 230-243. https://doi.org/10.1002/JPER.22-0226

Thoma, D. S., Gasser, T. J. W., Jung, R. E., & Hämmerle, C. H. F. (2020). Randomized controlled clinical trial comparing implant sites augmented with a volume-stable collagen matrix or an autogenous connective tissue graft: 3-year data after insertion of reconstructions. *Journal of Clinical Periodontology*, 47, 630-639. https://doi.org/10.1111/jcpe.13271

Thoma, D. S., Naenni, N., Figuero, E., Hammerle, C. H. F., Schwarz, F., Jung, R. E., & Sanz-Sanchez, I. (2018). Effects of soft tissue augmentation procedures on peri-implant health or disease: A systematic review and meta-analysis. *Clinical Oral Health Research*, 29(Suppl 15), 32-49. https://doi.org/10.1111/clr.13114

Tonetti, M. S., Chapple, I. L., Jepsen, S., & Sanz, M. (2015). Primary and secondary prevention of periodontal and peri-implant diseases: Introduction to, and objectives of the 11th European workshop on periodontology consensus conference. *Journal of Clinical Periodontology*, 42(Suppl 16), S1-S4. https://doi.org/10.1111/jcpe.12382

Truhlar, R. S., Morris, H. F., & Ochi, S. (2000). The efficacy of a counter-rotational powered toothbrush in the maintenance of endosseous dental implants. *Journal of the American Dental Association* (1939), 131, 101-107. https://doi.org/10.14219/jada.archive.2000.0028

Vellis, J., Kutkut, A., & Al-Sabbagh, M. (2019). Comparison of xenogeneic collagen matrix vs. free gingival grafts to increase the zone of keratinized mucosa around functioning implants. *Implant Dentistry*, 28, 20-27. https://doi.org/10.1097/id.0000000000000842

WHO. (2017). Monograph on tobacco cessation and oral health integration. World Health Organization.

Zheng, C., Wang, S., Ye, H., Liu, Y., Hu, W., & Zhou, Y. (2021). Effect of free gingival graft before implant placement on peri-implant health and soft tissue changes: A randomized controlled trial. *BMC Oral Health*, 21, 492. https://doi.org/10.1186/s12903-021-01818-3

Ziebolz, D., Klipp, S., Schmalz, G., Schmickler, J., Rinke, S., Kottmann, T., Fresmann, S., & Einwag, J. (2017). Comparison of different maintenance strategies within supportive implant therapy for prevention of peri-implant inflammation during the first year after implant
Journal of Clinical Periodontology, 49, 1346-1356. https://doi.org/10.1111/jcpe.13716

Roccuzzo, M., Bonino, F., Aglietta, M., & Dalmasso, P. (2012). Ten-year results of a three arms prospective cohort study on implants in peri-odontally compromised patients. Part 2: Clinical results. *Clinical Oral Implants Research*, 23, 389-395. https://doi.org/10.1111/j.1600-0501.2011.02309.x

Roccuzzo, M., Bonino, L., Dalmasso, P., & Aglietta, M. (2014). Long-term results of a three arms prospective cohort study on implants in peri-odontally compromised patients: 10-year data around sandblasted and acid-etched (SLA) surface. *Clinical Oral Implants Research*, 25, 1105-1112. https://doi.org/10.1111/clr.12227

Roccuzzo, M., De Angelis, N., Bonino, L., & Aglietta, M. (2010). Ten-year results of a three-arm prospective cohort study on implants in peri-odontally compromised patients. Part 1: Implant loss and radiographic bone loss. *Clinical Oral Implants Research*, 21, 490-496. https://doi.org/10.1111/j.1600-0501.2009.01886.x

Roccuzzo, M., Grasso, G., & Dalmasso, P. (2016). Keratinized mucosa around implants in partially edentulous posterior mandible: 10-year results of a prospective comparative study. *Clinical Oral Implants Research*, 27, 491-496. https://doi.org/10.1111/clr.12563

Roman-Torres, C. V. G., Pasquinelli, F., Pimentel, A. C., de Melo, M. P., Rego, R. O., & Sendyk, W. R. (2019). The effects of annual maintenance on peri-implant health in patients rehabilitated with overdentures: A retrospective cohort study. *The International Journal of Oral & Maxillofacial Implants*, 34, 159-164. https://doi.org/10.11607/jomi.6815

Salvi, G. E., Aglietta, M., Eick, S., Sculean, A., Lang, N. P., & Ramseier, C. A. (2012). Reversibility of experimental peri-implant mucositis compared with experimental gingivitis in humans. *Clinical Oral Implants Research*, 23, 182-190. https://doi.org/10.1111/j.1600-0501.2011.02220.x

Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Beglundh, T., Sculean, A., Tonetti, M. S., EFP Workshop Participants and Methodological Consultants, Merete Aass, A., & Aimetti, M. (2020). Treatment of stage I-III periodontitis—The EFP S3 level clinical practice guideline. *Journal of Clinical Periodontology*, 47(Suppl 22), 4-60. https://doi.org/10.1111/jcpe.13290

Sanz, M., Schwarz, F., Herrera, D., McClain, P., Figuero, E., Molina, A., Montero, E., Pascual, A., Ramanauskaitė, A., Renouard, F., Sader, R., Schiegnitz, E., Urban, I., & Heitz-Mayfield, L. (2022). Importance of keratinized mucosa around dental implants: Consensus report of group 1 of the DGI/SEPA/Osteology Workshop. *Clinical Oral Implants Research*, 33(Suppl 23), 47-55. https://doi.org/10.1111/clr.13956

Schliephake, H. (2022). The role of systemic diseases and local conditions as risk factors. *Periodontology 2000*, 2000(88), 36-51. https://doi.org/10.1111/prd.12409

Schwarz, F., Alcoforado, G., Guerrero, A., Jonsson, D., Klinge, B., Lang, N., Mattheos, N., Mertens, B., Pitta, J., Ramanauskaitė, A., Sayardoust, S., Sanz-Martin, I., Stavropoulos, A., & Heitz-Mayfield, L. (2021). Peri-implantitis: Summary and consensus statements of group 3. The 6th EAO Consensus Conference 2021. *Clinical Oral Implants Research*, 32-(Suppl 21), 245-253. https://doi.org/10.1111/clr.13827

Schwarz, F., Derks, J., Monje, A., & Wang, H. L. (2018). Peri-implantitis. *Journal of Periodontology*, 89(Suppl 1), S267-S290. https://doi.org/10.1002/JPER.16-0350

Stang, A. (2010). Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. *European Journal of Epidemiology*, 25, 603-605. https://doi.org/10.1007/s10654-010-9491-z

Staubli, N., Walter, C., Schmidt, J. C., Weiger, R., & Zitzmann, N. U. (2017). Excess cement and the risk of peri-implant disease—a systematic review. *Clinical Oral Implants Research*, 28, 1278-1290. https://doi.org/10.1111/clr.12954

Sterne, J. A., Hernan, M. A., Reeves, B. C., Savovic, J., Berkman, N. D., Viswanathan, M., Henry, D., Altman, D. G., Ansari, M. T., Boutron, I., Carpenter, J. R., Chan, A.-W., Churchill, R., Deeks, J. J., Hróbjartsson, A., Kirkham, J., Jüni, P., Loke, Y. K., Pigott, T. D., ... Higgins, J. P. (2016). ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions. *BMJ*, 355, i4919. https://doi.org/10.1136/bmj.i4919

Swierkot, K., Brusius, M., Leismann, D., Nonnenmacher, C., Nusing, R., Lubbe, D., Schade-Brittinger, C., & Mengel, R. (2013). Manual versus sonic-powered toothbrushing for plaque reduction in patients with dental implants: An explanatory randomised controlled trial. *European Journal of Oral Implantology*, 6, 133-144.

Tawil, G., Younan, R., Azar, P., & Sleilati, G. (2008). Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long-term clinical results. *The International Journal of Oral & Maxillofacial Implants*, 23, 744-752.

Thoma, D. S., Cosyn, J., Fickl, S., Jensen, S. S., Jung, R. E., Raghoebar, G. M., Rocchietta, I., Roccuzzo, M., Sanz, M., Sanz-Sánchez, I., Scarlat, P., Schou, S., Stefanini, M., Strasding, M., Bertl, K., Working Group 2 of the 6th EAO Consensus Conference 2021, & Bertl, K. (2021). Soft tissue management at implants: Summary and consensus statements of group 2. The 6th EAO Consensus Conference 2021. *Clinical Oral Implants Research*, 32(Suppl 21), 174-180. https://doi.org/10.1111/clr.13798

Thoma, D. S., Gasser, T. J. W., Hammerle, C. H. F., Strauss, F. J., & Jung, R. E. (2023). Soft tissue augmentation with a volume-stable collagen matrix or an autogenous connective tissue graft at implant sites: 5-year results of a randomized controlled trial post implant loading. *Journal of Periodontology*, 94(2), 230-243. https://doi.org/10.1002/JPER.22-0226

Thoma, D. S., Gasser, T. J. W., Jung, R. E., & Hämmerle, C. H. F. (2020). Randomized controlled clinical trial comparing implant sites augmented with a volume-stable collagen matrix or an autogenous connective tissue graft: 3-year data after insertion of reconstructions. *Journal of Clinical Periodontology*, 47, 630-639. https://doi.org/10.1111/jcpe.13271

Thoma, D. S., Naenni, N., Figuero, E., Hammerle, C. H. F., Schwarz, F., Jung, R. E., & Sanz-Sanchez, I. (2018). Effects of soft tissue augmentation procedures on peri-implant health or disease: A systematic review and meta-analysis. *Clinical Oral Health Research*, 29(Suppl 15), 32-49. https://doi.org/10.1111/clr.13114

Tonetti, M. S., Chapple, I. L., Jepsen, S., & Sanz, M. (2015). Primary and secondary prevention of periodontal and peri-implant diseases: Introduction to, and objectives of the 11th European workshop on periodontology consensus conference. *Journal of Clinical Periodontology*, 42(Suppl 16), S1-S4. https://doi.org/10.1111/jcpe.12382

Truhlar, R. S., Morris, H. F., & Ochi, S. (2000). The efficacy of a counter-rotational powered toothbrush in the maintenance of endosseous dental implants. *Journal of the American Dental Association* (1939), 131, 101-107. https://doi.org/10.14219/jada.archive.2000.0028

Vellis, J., Kutkut, A., & Al-Sabbagh, M. (2019). Comparison of xenogeneic collagen matrix vs. free gingival grafts to increase the zone of keratinized mucosa around functioning implants. *Implant Dentistry*, 28, 20-27. https://doi.org/10.1097/id.0000000000000842

WHO. (2017). Monograph on tobacco cessation and oral health integration. World Health Organization.

Zheng, C., Wang, S., Ye, H., Liu, Y., Hu, W., & Zhou, Y. (2021). Effect of free gingival graft before implant placement on peri-implant health and soft tissue changes: A randomized controlled trial. *BMC Oral Health*, 21, 492. https://doi.org/10.1186/s12903-021-01818-3

Ziebolz, D., Klipp, S., Schmalz, G., Schmickler, J., Rinke, S., Kottmann, T., Fresmann, S., & Einwag, J. (2017). Comparison of different maintenance strategies within supportive implant therapy for prevention of peri-implant inflammation during the first year after implant
restoration. A randomized, dental hygiene practice-based multicenter study. *American Journal of Dentistry*, 30, 190–196.

## SUPPORTING INFORMATION

Additional supporting information can be found online in the Support-
ing Information section at the end of this article.

**How to cite this article:** Carra, M. C., Blanc-Sylvestre, N., Courtet, A., & Bouchard, P. (2023). Primordial and primary prevention of peri-implant diseases: A systematic review and meta-analysis. *Journal of Clinical Periodontology*, 50(Suppl. 26), 77-112. https://doi.org/10.1111/jcpe.13790
restoration. A randomized, dental hygiene practice-based multicenter study. *American Journal of Dentistry*, 30, 190-196.

## SUPPORTING INFORMATION

Additional supporting information can be found online in the Support-
ing Information section at the end of this article.

**How to cite this article:** Carra, M. C., Blanc-Sylvestre, N., Courtet, A., & Bouchard, P. (2023). Primordial and primary prevention of peri-implant diseases: A systematic review and meta-analysis. *Journal of Clinical Periodontology*, 50(Suppl. 26), 77-112. https://doi.org/10.1111/jcpe.13790