The population (P) of adult patients in this SR was those 18 years or older with a dental implant, not affected by systemic conditions (i.e., diabetes, autoimmune diseases), cancers, HIV/AIDs, or any form of tobacco use. The intervention (I) was oral self-care practices with no comparison (C). The outcome (O) was the prevention and management of peri-implant conditions and diseases.

The included studies were United States (US) and international peer-reviewed articles, studies with randomized research designs, clinical trials, observational studies, meta-analysis, systematic reviews, and reviews that included at least one keyword from the “oral self-care practices” or “outcomes” category. Letters, editorials, or comments, cohort studies, and case studies were excluded. Moreover, studies with unhealthy patients/populations with an implant [systemic conditions (i.e., diabetes, autoimmune diseases), smokers, cancers, HIV/AIDs] and those that included professional prevention or management of a peri-implant disease or condition from a licensed oral health profession [i.e., non-surgical periodontal therapy (NSPT) (i.e., hand instrumentation, ultrasonic scaling, or piezo scaling), air-polishing, locally delivered antibiotics, irrigation (chairside irrigation), or surgical periodontal therapy (i.e., implantoplasty/gingival or bone graft) were also excluded.

A search was conducted using a combination of controlled vocabulary and natural language keywords. The search was designed by a health science librarian (NT-M) and included the concepts of peri-implants and oral self-care practices (i.e., interdental aids, dental floss, manual and electronic toothbrushes, therapeutic irrigation, and toothpaste), and periodontal indices {[i.e., Silness and Löe indices [gingival (GI) and plaque indices (PI)]} and plaque scores [O’Leary plaque score and Quigley and Hein index (later modified by Turesky et al.)].

A search was developed for Medline(R)ALL and then translated and executed across five additional databases: Embase + Embase Classic (via Ovid), Cinahl, Dentistry and Oral Sciences Source (EBSCO), Scopus, and Web of Science Core Collection (SCI-EXPANDED, SSCI, AHCI, CPCI-S, CPCI-SSH, BKCI-SSH, ESCI, CCR-EXPANDED, and IC) from their inception to 16 April 2025 (Appendix with Search Strategies). The results were limited to studies on humans and in English, and excluded letters, commentary, and editorials.

Results were then exported to Covidence for deduplication and screening against the inclusion and exclusion criteria (19). The two co-primary investigators (PIs) independently and blindly screened titles and abstracts against the inclusion criteria. A virtual Zoom (Zoom; San Jose, CA, USA) meeting occurred on 14 May 2025 for the two co-PIs to discuss conflicts and undetermined articles until an agreed consensus was achieved. The full-text articles were then reviewed and 12 met the exclusion criteria.

The risk of bias in systematic reviews (ROBIS) tool (20) was used to assess the risk of bias in four systematic reviews (n = 4) (21–24). The tool is implemented in the following three phases: (1) assess the review's relevance, (2) identify potential issues in the review process, and (3) evaluate the risk of bias (20). In phase 2, the following four key areas where bias may occur in a systematic review are examined: study eligibility criteria, how studies were identified and selected, data collection and appraisal methods, and the synthesis and interpretation of findings. Phase 3 involves judging the overall risk of bias in how the review findings are interpreted, considering any limitations flagged in phase 2 (20).

The revised Cochrane risk of bias tool for randomized trials (RoB2) (25) was used for nine studies (n = 8) (26–33). The five domains, namely, (1) bias arising from the randomization process, (2) bias due to deviations from intended interventions, (3) bias due to missing outcome data, (4) bias in measurement of the outcome, and (5) bias in selection of the reported result, were rated either (a) low risk of bias, (b) some concerns, or (c) high risk of bias (25).

The search yielded a total of 3,161 articles with 1,486 remaining after the duplicates were removed (Figure 1). The search and selection process is outlined in Figure 1. The articles in this systematic review were categorized into the following five domains: (1) toothbrushes, n = 3; (2) interdental aids, n = 4; (3) toothpaste, n = 3; (4) mouth rinses and topicals, n = 1; and (5) multiple oral self-care interventions, n = 1. The domains were further separated into the following categories: toothbrushes: (a) manual and (b) electric; interdental aids: (a) floss, (b) interdental brushes, and (c) oral irrigation; toothpaste: (a) fluoride toothpaste and (b) triclosan toothpaste; mouth rinses and topicals: (a) chlorhexidine (CHX) and (b) essential oils.

Table 1 presents the study characteristics. In the 12 studies in this systematic review, adult patients at least 18 years of age or older were included (21–24, 26–33). The majority of the studies included only healthy, non-smokers, with at least one dental implant (26–28, 31–33). One study did not disclose the health or smoking status of the participants (29). The SRs and narrative reviews also only included adults who were in good general health and non-smokers (23). Two SRs (21, 24) and one review of the literature (22) did not mention the inclusion criteria for the participants. Two double-blind randomized controlled trials (RCTs) with parallel groups (26, 27), one single-blind three-group parallel RCT (33), two single-examiner-masked RCTs (31, 32), two RCTs (28, 30), one longitudinal multicenter RCT (29), two SRs (21, 24), one literature review (22), and one narrative review (23) were included.

The intervention durations were 6 months for two studies (26, 27), 3 months for one study (28), 1 month for three studies (31, 32), and 2weeks for two studies (30, 33). One study was longitudinal, with a duration of 24 months (29). The interventions were triclosan- and fluoride-containing dentifrices in two studies (26, 27) and one SR focused on the effectiveness of triclosan-containing dentifrices in peri-implant diseases (21). Mouthwashes or gels containing CHX or stannous fluoride were the interventions in one study (30). Interdental aids, namely, interproximal brushes, oral irrigation, or dental floss, were the interventions in three (31–33) and there was one SR focused on these interventions (24). Moreover, toothbrushes, including oscillating, sonic, or manual toothbrushes, were the interventions in two studies (28, 29). One literature review included three domains from this SR (toothbrushes, interdental aids, and mouthwash) (22).

The clinical measures reported were probing depth (PD) (22, 24, 27–29, 31, 32), recession (REC) (29), clinical attachment level (CAL) (24, 29), BoP or sulcular bleeding index (SBI) (22, 24, 26–28), Löe and Silness PI (22, 23, 26–29, 33), or GI (23, 24, 26). The calculus index (CI) was reported in one study (29) and microbial assay or peri-implant crevicular fluid (PICF) was reported in four studies (21, 26, 30, 33). A risk of bias in reporting was noted in two studies (23, 24). The strengths of these studies are presented in Table 1. The observed limitation in a number of the studies was the lack of reporting guidelines or registries (21–23, 27–33).

Of the 12 articles in this systematic review, four were evaluated using the ROBIS tool (Table 2). In phase 1, we assessed the relevance of the studies, including the patients/population, interventions, comparators, and outcomes (Table 1) (21–24). One SR had a high risk of bias due to the total number of focused research questions (five), having limited key words (two total), and having only one screener for the inclusion and exclusion criteria (21). The SR by Gandhi et al. was deemed to have a low risk of bias for all domains in the ROBIS tool (24). The SR by Preda et al. generally had a low risk of bias, with the exception in phase 3 due to only having one reviewer (23). The SR by Checchi et al. covered a wide range of oral hygiene practices and was deemed low risk of bias for domains 1 and 2 in phase 2, but was deemed to have a high risk of bias for domain 3 in phase 2 (22). This high risk of bias was determined because no risk of bias validation tool was used and the authors categorized evidence against the inclusion criteria, which may have bias (22).

A total of eight studies were evaluated using RoB2 (Table 3). For domain 1, i.e., the risk of bias arising from the randomization process, five studies had a low risk (26, 28, 30–32) and two had some concerns (27, 28). For domain 2, i.e., the risk of bias due to deviations from the intended interventions, two studies had a low risk (26, 27) and five studies had some concerns (28–32). For domain 3, i.e., missing outcome data, five studies had a low risk (26–28, 31, 32) and two studies had some concerns (29, 30). For domain 4, i.e., risk of bias in measurement of the outcome, five studies had a low risk (26, 27, 29, 31, 32) and two studies had some concerns (28, 30). For domain 5, i.e., risk of bias in the selection of the reported results, four studies had low risk (26, 28, 31, 32) and three studies had some concerns (27, 29, 30). All the studies assessed using RoB2 had some concerns overall (27–32), except one, which had a low risk of bias overall. A quantitative synthesis was not performed due to wide heterogeneity among studies in terms of study design, intervention and comparator groups, and study duration.

Clinical trials consistently support the use of triclosan-containing dentifrices (0.3% triclosan with 2.0% polyvinylmethyl ether (PVM)/maleic acid (MA) copolymer and fluoride) in reducing plaque, BoP, and PD around dental implants (21, 26, 27). Compared to standard sodium fluoride toothpaste, triclosan formulations show statistically significant reductions in gingival inflammation and microbial load, including periodontal pathogens such as Porphyromonas gingivalis and Tannerella forsythia (26). These findings support Ribeiro et al.’s investigation of triclosan-containing toothpaste as a protective approach to prevent peri-implant tissue inflammation (34). Interestedly, Ribeiro et al. identified reduced inflammation measures and BoP, even in the presence of biofilm (34). A triclosan-containing toothpaste may help reduce inflammation and support the host response around peri-implant tissue, even without standard oral hygiene practices for biofilm management (21, 26, 27, 34). This evidence suggests triclosan-containing toothpaste is a valuable adjunct to consider as a best practice for preventing peri-implant diseases due to its anti-inflammatory properties, which may potentially decrease the need for more invasive interventions. Based on the evidence, dental professionals should consider recommending triclosan-containing toothpaste as part of a comprehensive peri-implant maintenance program while also emphasizing proper brushing techniques to maximize its benefits. Regular clinical assessments should also be performed to evaluate the impact of triclosan toothpaste on peri-implant soft tissue health to further help guide personalized oral hygiene strategies.

The use of mouth rinses has long been indicated as an adjunct to traditional tooth brushing and flossing for control of peri-implant biofilm. Traditionally, 0.12% chlorhexidine digluconate and essential oils have both been shown to be clinically effective in the prevention of peri-implant disease by inhibiting and reducing the formation of biofilm (35). Though historically used, a randomized clinical study now indicates that chlorhexidine may elevate inflammatory markers; therefore, long-term use should be approached cautiously due to its potential side effects (30). Interestingly, stannous fluoride/amine fluoride rinses, particularly when used without adjunctive chlorhexidine, specifically demonstrated potential in reducing inflammatory cytokines such as interleukin 1β (IL-1β) and vascular endothelial growth factor (VEGF) in peri-implant crevicular fluid. While only one mouth rinse study was included in this systematic review, this evidence strongly indicates that stannous fluoride/amine fluoride rinses should be considered as an alternative for peri-implant health. The potential anti-inflammatory benefits of stannous fluoride/amine fluoride rinses warrant consideration in patients, especially in those with early signs of peri-implant inflammation or those at risk for biofilm accumulation. Future recommendations should prioritize these formulations over chlorhexidine for routine use, reserving chlorhexidine for short-term, targeted interventions. It is vital that dental professionals provide clear patient education on proper adjunctive rinse use to sustain peri-implant health.

Biofilm removal between implants is vital and interproximal brushes showed superior outcomes in reducing the clinical indicators of peri-implant diseases and inflammatory markers (e.g., IL-6) compared to dental floss and water flossers (22, 24, 31–33). Nevertheless, oral irrigators, especially when combined with toothbrushing, significantly reduce BoP and the presence of pathogenic bacteria compared to flossing alone (33) and were reported as an appropriate adjunct to toothbrushing for the management of peri-implant tissues (24). It is important to note that the findings from this systematic review support the inclusion of interdental aids as a best practice for the prevention and management of peri-implant diseases; however, patient preferences, dexterity, and implant configuration should be considered when making professional recommendations for oral self-care strategies.

Patients with dental implants often have unique needs based on their implant location and prosthetic design. Choosing the right toothbrush tailored to those needs ensures more effective maintenance and better outcomes. Powered toothbrushes, including oscillating-rotating and counter-rotating models, are more effective than manual toothbrushes at reducing plaque and gingival inflammation (29). Studies show that oscillating-rotating heads may offer better outcomes at implant sites than sonic brushes in the short term, although long-term benefits are comparable (23, 28). These devices also enhance patient compliance and ease of use, which are critical in peri-implant health. Clinically, these findings highlight the importance of individualized oral hygiene instruction and toothbrush device selection for implant patients. The superior short-term plaque control observed with oscillating-rotating powered brushes supports their recommendation as a home care tool, particularly for individuals with limited dexterity or complex prosthetic designs. Toothbrush recommendations should be tailored to each patient's prosthetic design and accessibility and their manual dexterity.

Appropriate modes of at-home oral self-care are necessary to maintain peri-implant health. A multimodal approach combining a powered toothbrush, interproximal brushes or oral irrigators, and an evidence-supported dentifrice (e.g., triclosan-based) is most effective for long-term peri-implant maintenance (22). Oral health providers must understand the significance of patient home care and patient adherence to multiple interventions to deliver effective education and reinforce proper at-home techniques. Clinically, these findings emphasize the importance of a comprehensive, evidence-based home care routine for implant patients. The integration of multiple self-care interventions offers superior biofilm control compared to single-method approaches. Effective clinical implementation requires ongoing patient education, individualized product selection, and reinforcement of proper techniques during maintenance appointments to ensure patients can achieve optimal peri-implant tissue stability through consistent home care.

The strengths of this systematic review include reporting in accordance with the PRISMA 2020 statement (16) and the protocol was registered in the PROSPERO database (CRD420251028140). In addition, the search was designed by a health sciences librarian (NT-M). The limited number of articles (n = 12) in this systematic review is a limitation and reduces the generalizability of the outcomes. It is noteworthy that the first line of defense for peri-implant diseases and conditions is professional treatment interventions. The exclusion of studies that included professional treatment interventions (i.e., non-surgical scaling and root planing, periodontal maintenance, and prophylaxis) in conjunction with the intervention is a limitation. The exclusion criteria may have omitted studies that would have provided insights transferable to other populations and peri-implant diseases and conditions. The lack of studies on patient education for oral self-care, dietary interventions, and probiotics is also a limitation. These studies may have provided alternative interventions to reduce peri-implant diseases and conditions.

The overall certainty of the evidence in this systematic review was moderate to low.

The SR by Trombelli and Farina had a high risk of bias related to the number of research questions, limited key words, having only one screener, and having no information on minimizing error in data collection (21). The SR by Checchi et al. did not use a validated risk of bias tool and used the inclusion and exclusion criteria, which may have resulted in bias (22). The SR by Preda et al. only had one screener, which may have resulted in bias (23).

After applying the ROBIS tool, the SR by Gandhi et al. had the lowest risk of bias (24).

As for the certainty of evidence after applying RoB2, the study by Sreenivasan et al. had an overall low risk of bias (26). The remaining seven studies all demonstrated some concerns (27–33). These were largely related to domain 2, specifically, the participants being aware of their assigned intervention. However, it is important to note that in these specific studies (28–33), masking participants to their assigned intervention was not feasible. Two studies (29, 30) did not mention the extent of missing data or attrition; therefore, “no information” was documented for domain 3 and these studies were deemed to be of some concern. It was unclear in two studies (28, 30) whether the examiner was masked and this resulted in them being of some concern for domain 4. Two studies (29) provided no information about a pre-specified analysis plan and were deemed of some concern for domain 5. Despite the certainty of evidence based on the ROBIS tool and RoB2, this systematic review achieved the goal of itemizing the domains and categories for optimal home care devices, aids, and adjuncts for peri-implant diseases and conditions. Furthermore, this systematic review and its protocol were registered on PROSPERO, which did not indicate that the authors should be contacted for missing information to determine risk of bias.

Future clinical research should further investigate evidence-based oral self-care practices to support peri-implant health, while emphasizing patient education and awareness of peri-mucositis as a critical strategy for preventing peri-implantitis. Given the growing shortage of dental care providers in many regions, consistent access to professional implant maintenance may be limited. This makes effective home care even more essential, particularly for patients facing geographic, economic, or systemic barriers to care. Future systematic reviews should consider including studies with professional interventions and PICOT (PICO with the addition of timeframe) to determine whether the duration of the oral self-care intervention is a critical determinant of the intervention's effect or the outcome's relevance. In addition, future research should consider the patient’s history of periodontitis, the type of implant prosthesis, and the functional time of the implant. These criteria may provide beneficial evidence on best practices for oral self-care based on the stage of periodontitis, implant disease classification, and cleansing ability based on implant restoration type. Furthermore, the development and implementation of standardized clinical guidelines for both in-office implant maintenance and at-home oral hygiene instruction are necessary to promote consistency in care and optimize outcomes across diverse populations.