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Peri-implant diseases, whether reversible or with progressive bone loss, are a growing concern for clinicians. Due to the growth of dental implant therapy in recent years, early intervention and prevention strategies for peri-implantitis and mucositis have become paramount to ensure long-term implant success in our practices.
Understanding Peri-Implant Diseases
Mucositis vs. Peri-implantitis
Literature defines peri-implant mucositis as the inflammation of peri-implant soft tissues without bone loss. Contrarily, peri-implantitis includes mucosal inflammation and progressive bone destruction. Mucositis is often the precursor stage to peri-implantitis and can progress into irreversible bone loss if left untreated.
Quick Review of Epidemiology & Risk Factors
Peri-implant mucositis affects approximately 30–50% of implants, while peri-implantitis is less prevalent, with an estimate of approximately 10–20%.
Some risk factors include:
- Poor oral hygiene
- History of periodontitis
- Severe smoking
- Uncontrolled systemic conditions like diabetes and obesity
- Unfavorable prosthetic design
- Gait of soft tissue, including keratinized mucosa
-
Implant malposition
While some of these factors are generalized and frequent in almost every population, they require extra vigilance in our clinical protocols, as smoking rates and medical conditions can vary greatly between regions.
Frequent Causes and Pathogenesis
Microbial Biofilm and Dysbiosis
Microbial biofilm is the primary driver of peri-implant disease. While early formed biofilm is common and easily removable, it can evolve into a pathogenic community dominated by Gram-negative anaerobes that induce inflammation, infection, and soft tissue migration.
Besides, dental implants’ rough surface can facilitate dysbiotic colonization and hinder hygiene efforts if the protocol is not appropriate or patient compliance is not optimal. Thus, post-operative instructions, oral hygiene, and maintenance are crucial to prevent complications.
Host Immune Response and Bone Resorption
Oral biofilm can trigger an inflammatory cascade that involves cytokines, like IL-1β, TNF-α, and RANKL, leading to osteoclast activation and bone resorption. This interaction can lead to progressive bone loss around implants if left untreated.
Iatrogenic and Mechanical Factors
As clinicians, we can also be culprits of implant failure. A poor prosthetic design, leaving cement remnants, shaping inadequate emergence profiles, or causing implant misalignment will often predispose patients to periodontal disease. Particularly, excess cement has been strongly associated with higher peri-implantitis risk.
Prevention Strategies
Patient Education and Maintenance
Prevention must begin before implant placement and continue through functional loading and beyond. Literature suggests following a structured supportive peri-implant care (SPIC) program, which includes the following aspects:
- Regular monitoring
- Plaque control
- Risk factor management
- Patient motivation and compliance
By integrating these factors into our rehabilitation, this program has shown reduced incidence and recurrence of peri-implant disease.
Prosthetic Design Considerations
Current evidence suggests opting for screw-retained restorations when possible to avoid residual cement issues. Design emergence profiles to facilitate easy hygiene access and minimize plaque retention whenever possible.
Risk Factor Management
As clinicians, we must address modifiable risks, such as supporting smoking cessation, ensuring glycemic control in diabetic patients, and considering antiseptic support with chlorhexidine rinse or specialized hygiene tools when necessary.
Early Detection and Management of Mucositis
Early Clinical Signs
Peri-implant disease is characterized by soft tissue signs like bleeding on probing (BOP), swelling, and erythema, without radiographic bone loss. Thus, establishing baseline probing depths and regular evaluation helps detect subtle changes promptly.
Non-Surgical Therapy
First-line of treatment includes mechanical debridement, using specialized tools like implant surface cleaning brushes, and hygiene reinforcement. However, current studies have shown that debridement combined with chlorhexidine mouthwash and gel significantly improves BOP compared to debridement alone.
Other adjunctive therapies include:
- Photodynamic therapy (PDT)
- Laser therapy
- Air-powder polishing, especially with erythritol.
Typically, a combination of these therapies is more effective than isolated measures to reduce probing depth, plaque index, and BOP.
Improving Mucositis Outcomes
Being consistent with mechanical therapy and hygiene reinforcement is essential to achieve the best mucositis resolution rates. In practice, the strongest predictor of reversal is patient compliance and adherence supported by professional maintenance.
Treatment Protocols for Peri-Implantitis
Non-Surgical Approaches
While non-surgical debridement can be the initial step for early stages of the disease, it may not be sufficient. Adjunct therapies like antibiotics, lasers, air-abrasive devices, and phototherapy may enhance outcomes but are rarely definitive.
Surgical Protocols
When peri-implantitis has already been established and progresses beyond the capacity of non-surgical therapy, we can opt for surgical approaches. These treatments provide us direct access to the contaminated implant surface, allowing us to debride, detoxify, and reshape peri-implant tissues. Some of these protocols include:
Resective Surgery
This approach focuses on eliminating peri-implant rockets while reshaping hard and soft tissues to reduce bacterial colonization. The surgical techniques typically include apically repositioned flaps combined with implantoplasty, which involves the mechanical smoothing of exposed implant threads with specialized cleaning brushes and burs. This debridement enables us to thoroughly clean the implant surface while reducing surface roughness. It also decreases plaque retention and makes future hygiene easier.
This approach is particularly effective in reducing pocket depth in non-esthetic areas, such as posterior regions with lower esthetic demands. As a downside, implantoplasty typically sacrifices some peri-implant tissue height and contour, limiting its use in the anterior zone.
Regenerative surgery
Regenerative procedures aim to restore lost bone around the implant in cases with vertical or circumferential bone defects. This process involves thorough surface decontamination followed by the placement of bone grafts, whether autogenous or synthetic, and barrier membranes.
Most systematic reviews indicate that regenerative surgery can achieve significant bone fill and re-osseointegration, particularly in well-contained defects.
The choice of material and technique depends on defect morphology, patient risk profile, and implant surface conditions. However, while regenerative therapies show promising outcomes, it’s less predictable than resective therapy and demand meticulous case selection.
Adjunctive Therapies
Systemic antibiotics may show useful effects in acute or refractory cases if we follow the appropriate protocols to prevent antibiotic resistance. Currently, novel adjuncts that have shown promise but require more evidence include the use of probiotics, photodynamic therapy, and growth factors.
Another adjunctive option that’s showing promising results in surface decontamination is the Ten-Second Technique (TST), which combines antiseptic gels with air polishing. However, this alternative is barely on trials and requires more evidence to be clinically applicable.
Evidence-Based Clinical Flow
Current evidence and consensus diagrams recommend:
- Early risk assessment and diagnosis
- Nonsurgical management of mucositis
- Escalation to surgical treatment for peri-implantitis
- Inclusion of maintenance therapy post-treatment to sustain health and prevent recurrence.
This protocol emphasizes tailored treatment plans, continuous re-evaluation, and lifelong maintenance.
Patient Instructions and Home Care
Even the best surgical protocols end up in failure without patient compliance and care. As a result, our role as clinicians in implant restoration extends beyond the operatory, requiring active cooperation from patients to prevent peri-implant disease.
Effective home care significantly reduces the risk of mucositis and peri-implantitis, but the opposite is also true. Therefore, patients should be instructed to:
- Use the appropriate brushing technique, adapted to the patient’s needs and limitations.
-
Use of complementary hygiene tools like interdental brushes, Superfloss, or other tools specifically designed for implants to remove plaque in hard-to-reach areas.
Incorporate antimicrobial rinses, particularly with 0.12–0.2% chlorhexidine, when the risk of mucositis is high, but only under prescription to avoid staining. - Avoid smoking or reduce smoking consumption, as it markedly increases peri-implantitis risk and implant failure.
- Maintain a balanced diet, with attention to glycemic control and anti-inflammatory foods in diabetic patients.
- Our role in this stage is to emphasize that implants, like natural teeth, require daily attention and care. While our role with home care is limited to instructions and motivation, reinforcing these protocols during each recall visit ensures compliance and strengthens long-term success.
Emerging Research and Future Directions
Peri-implantitis management remains one of the most actively researched areas in implant dentistry. Although current treatment protocols focus on mechanical and surgical strategies, novel biologically driven approaches are under investigation.
Current approaches often aim for biomimetic implant surface modifications to reduce bacterial adhesion while enhancing soft tissue integration. By lowering susceptibility to microbial colonization, these next-generation surfaces aim to create a “bio-shield”.
Another promising line of research, still in animal trials, involves host-modulation therapy, which targets the inflammatory cascade rather than the bacteria alone. This is done through agents that block pro-inflammatory cytokines, dampen the destructive immune response, and preserve bone.
Frequently Asked Questions (FAQs)
How often should patients with implants attend professional maintenance?
Typically, every 3–6 months is a great timeframe for regular check-ups, but it may vary depending on risk profile. Patients with a history of periodontitis or systemic risk factors, like diabetes, often benefit from shorter recall intervals.
How efficient are water flossers for implant maintenance?
When combined with the appropriate brushing, water flossers improve plaque control around difficult-to-reach areas, especially under implant-supported prostheses, whether bridges or dentures.
What type of toothpaste is the most adequate for implant patients?
The best alternatives include low-abrasive, non-whitening toothpastes to avoid damaging implant surfaces or creating microretentions. It also prevents peri-implant tissue damage, keeping gums healthy and firm.
How effective are probiotics in peri-implantitis prevention?
Current evidence suggests that probiotics may reduce soft tissue inflammation when combined with standard hygiene, but they should never replace mechanical plaque control. They’re particularly useful in preventing antibiotic resistance in long-term antibiotic therapies without resolution and when facing other systemic limitations.
How to protect implants from bacterial leakage?
Proper oral hygiene and routine professional maintenance are essential for reducing bacterial leakage around implants. To further enhance protection, sealing the implant–abutment micro-gap with products like GDT Anti-Virus Gel helps lower the risk of peri-implantitis.
Conclusion
Peri-implant mucositis and peri-implantitis remain significant threats to implant longevity, affecting many patients worldwide. However, they’re manageable with evidence-based, structured approaches.
Nonetheless, prevention, early identification, patient compliance, and timely intervention are crucial factors to prevent the disease or treat it timely. While, as clinicians, we cannot control patient hygiene and home measures, we can protect implant health by committing to risk assessment, meticulous prosthetic design, and adherence to SPIC protocols.
References
- Hong, I., Koo, K. T., Oh, S. Y., Park, H. W., Sanz-Martín, I., & Cha, J. K. (2024). Comprehensive treatment protocol for peri-implantitis: an up-to-date narrative review of the literature. Journal of periodontal & implant science, 54(5), 295–308. https://doi.org/10.5051/jpis.2303360168
- Perussolo, J., Donos, N. Maintenance of peri-implant health in general dental practice. Br Dent J 236, 781–789 (2024). https://doi.org/10.1038/s41415-024-7406-8
- Wang HL, Avila-Ortiz G, Monje A, Kumar P, Calatrava J, Aghaloo T, Barootchi S, Fiorellini JP, Galarraga-Vinueza ME, Kan J, Lin GH, Ravida A, Saleh MHA, Tavelli L; AO/AAP Consensus Participants; Rosen PS. AO/AAP consensus on prevention and management of peri-implant diseases and conditions: Summary report. J Periodontol. 2025 Jun;96(6):519-541. doi: 10.1002/JPER.25-0270. Epub 2025 Jun 12. PMID: 40501397; PMCID: PMC12273748.
