Journal of Dental Health and Oral Research

Open Access Review Article

Current Understanding and Treatment Strategies of Peri-Implant

Diseases - An Overview
Navjot Kaur1, Tarun Nanda2*, Baljeet Singh3, Sonia Nanda4
1
Associate Professor, Department of Dentistry, White Medical College and Hospital, Pathankot, Punjab, India
2
Professor, Department of Periodontology, Bhojia Dental College and Hospital, Baddi, HP, India
3
Principal, Department of Periodontology, Himachal Dental College and Hospital, Sundernagar, HP, India
4
Professor, Department of Prosthodontics, National Dental College and Hospital, Dera Bassi, Punjab, India
*
Corresponding Author: Tarun Nanda, Professor, Department of Periodontology, Bhojia Dental College and
Hospital, Baddi, HP, India; Email: dr_tarun_nanda@yahoo.co.in

Received Date: 23-08-2022; Accepted Date: 17-09-2022; Published Date: 24-09-2022

Copyright© 2022 by Kaur N, et al. All rights reserved. This is an open access article distributed under the terms
of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in
any medium, provided the original author and source are credited.

Abstract
As the general practitioners and specialists all over are placing dental implants with increased
confidence and expertise, so are the diseases and complications associated with them have
gained momentum. Peri-implant diseases consisting primarily of peri-implant mucositis and
peri-implantitis consists of soft tissue and hard tissue inflammation resulting in increased
clinical parameters such as pocket depth, clinical attachment loss, implant mobility along with
radiological findings of bone loss around the implant body and prosthesis. To manage these
infections, various treatment strategies have propped up in dentistry that one can mix and match
the different options according to the situation and do the needful. In this article, there is
description of peri-implant diseases, signs and symptoms that are associated with them and the
therapeutical options that can be applied to treat them. The goal of this article is to make the
diagnosis and therapy easy and narratable with the help of flowcharts, so that the reader whether
an academician or a clinician can understand the cause, effect of peri-implant diseases and can
correct them for the benefit of the patients.

Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
 2

Keywords

Peri-implant Diseases; Peri-Implant Mucositis; Peri-implantitis; Non-surgical Therapy;

Surgical Therapy

Abbreviation

VS: Visual Signs; BOP: Bleeding On Probing; PPD: Probing Pocket Depth; RBL:
Radiographic Bone Loss; OHS: Oral Hygiene Status; NST: Non-Surgical Therapy; AMT:
Anti-Microbial Therapy, AST: Antiseptic Therapy; RBD: Residual Bone Defect; EBL:
Extensive Bone Loss; OFD: Open Flap Debridement; DC/DD:
Decontamination/Detoxification; GBR: Guided Bone Regeneration; APF: Apically Positioned
Flap

Introduction

With the advent of implants in today’s world, newer and wider possibilities have cracked up to
replace the missing teeth in the patient’s oral cavity. Osseointegration of the implant structure
with the alveolar bone has led to a predictable treatment outcome in most of the cases. But, on
the same time, it has opened plethora of mechanical and biological complications which has
decreased the success and survival rate of implants. These complexities can arise due to various
factors out of which accumulation of biofilm causing inflammation of the soft and hard tissue
around the implant presents a major reckoning component in implant’s abidance.

The inflammatory lesions surrounding the implant body falls into the category of peri-implant
diseases, namely, peri-implant mucositis and peri-implantitis [1]. Peri-implant mucositis,
contrary to gingivitis, is an inflammation of the mucosa surrounding a functional implant and
peri-implantitis as in periodontitis is swelling of surrounding mucosa and bone loss beyond the
initial bone remodeling after the placement of the implant [2]. In a systemic review done with
metanalysis, the prevalence for peri-implant mucositis was reported at 43% ranging from 19%
to 65%, whereas for peri-implantitis, it amounted to 22% ranging from 1% to 47% [3].

Risk Factors

The causative factors which are responsible and increases the risk for the peri-implant diseases
can be broadly classified into patient associated and implant site and prosthesis associated
factors. The presence of microorganisms along with formation of biofilm causing infection

Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
 3

plays a significant role in initiation and progression of patient linked peri-implant diseases.
Outcomes from various animal and human studies have shown similarity in the composition of
bacteria in peri-implant diseases and gingivitis along with periodontitis, i.e gram negative
aerobes and anerobes [4,5]. Other aspects that can be linked to patient are poor plaque control,
lack of maintenance therapy, history of periodontal disease, active usage of tobacco products,
presence of systemic conditions in the form of diabetes mellitus, obesity, cardiovascular
conditions and genetic factors [6]. In site specific factors, implant surface characteristics, type,
prosthetic design, residual cement, peri-implant soft tissues and occlusal overload come into
play [7]. It has been hypothesized that rough surface implants harbor more bacteria than the
machined ones. Also, poor prosthetic design increases the risk of peri- implant diseases by
manifold times. Cement retained restorations are 3.6 times more prone to peri-implantitis when
compared with screw-retained prosthesis. Patients with insufficient soft tissue around the
implants are more susceptible to peri-implant infections [8]. Recently, tribocorrosion, in which
there is mechanical, microbial and chemical wear of the implant surface resulting in release of
titanium particles into the surrounding area and tissues causing peri-implant diseases have
become a heated topic over the years [9].

Case Definations of Peri-Implant Diseases

Coming to the diagnosis of peri-implant diseases, it is done through clinical, radiographical

and microbiological examination at various intervals. Before that, one must understand that
what constitutes peri-implant health. In health, there should be no visible signs of
inflammation, lack of profuse (line or drop) bleeding on probing, probing pocket depth should
not exceed ≤5 mm at any point of time and there should no further bone loss beyond the
physiological bone remodeling of upto 2 mm after the placement of implant and prosthesis. So,
clinically, any changes in the above said criteria’s will lead to peri-implant diseases [10]. The
placement of prosthesis will serve as the baseline criteria that should be followed over time to
see any changes in the clinical and radiographical level to diagnose the disease. The implant
shoulder or implant-abutment connection point will be the reference point for assessing the
changes in the interproximal bone level for peri-implantitis [11].

For peri-implant mucositis, clinically, there will be inflammation of the surrounding tissues in
the form of redness, swelling, abnormal contour and consistency or form of the soft tissue.
There will be the presence of bleeding on gentle probing with a constant force of 0.25 N cm
and suppuration will be there on palpation [12]. The probing pocket depths will be increased
as compared to baseline data and there will be absence of bone loss besides the initial
remodeling of the alveolar bone radiographically [13]. To assign a case of peri-implantitis, the
clinical picture of the site will demonstrate all the signs and symptoms of peri-implant

Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
 4

mucositis i.e redness and swelling, presence of bleeding on probing. Along with this, there will
be increased pocket depths and progressive bone loss after the placement of implant supported
prosthesis. For this, one has to have the baseline recordings of the pocket depth and
standardized periapical radiographs taken at baseline period and after 1 year or so [12]. If there
is absence of baseline data, then radiographic evidence of bone loss ≥3 mm and/or probing
depths ≥6 mm represents peri-implantitis [14].

Viability of implant can be assessed by mobility but existence of it merely does not indicate
peri-implantitis. Lack of osseointegration and loss of it after insertion of implant can have
variable causes such as improper placement, increased occlusal overload per SE. Due to
infectious nature of the peri-implant diseases, one can assume that microbiological examination
can be helpful in diagnosing the disease but so far it has been seen that there are no specific
bacterial profile that can be matched to peri-implant infection; so this criteria can be useful in
guidance of the treatment plan rather than in identifying the disease [15]. Genetically, there is
inconclusive evidence of the gene polymorphism linked to increased susceptibility of peri-
implantitis but in cases of smokers; there is seen positive correlation of peri-implantitis with
interleukin-1 gene polymorphism [16].

Treatment Planning and Considerations

In both the peri-implant diseases, whether it is mucositis or implantitis, the treatment planning
differs with respect to the type of disease. If the inflammation has just limited to the
perimucosal area and not gone and involved the alveolar bone, then, the use of systemic
antibiotics along with mechanical non-surgical therapy can suffice the disease. Otherwise, in
cases of peri-implantitis, surgical therapy has been proposed and has shown promising results
over the time [17]. As with gingivitis and periodontitis, long term and periodic maintenance
therapy and care are necessary to sustain the results of non-surgical and surgical implant
therapy (Fig. 1).

In context of peri-implant mucositis, if there is inflammation around the implants and natural
teeth in the oral cavity, then, one should focus on the oral hygiene status, smoking habits or
presence of any systemic condition such as diabetes mellitus and try to eliminate it. But, if the
infection is limited to one or more implants and the prosthesis is cemented, then, one should
look for the residual cement under the prosthesis and remove it and if there is any flaw in the
design of the prosthetic construction, then it should be taken off and fabricated again [18]. Use
of systemic antibiotics such as amoxicillin and metronidazole is validated in cases of abundant
suppuration, existence of sinus or fistula and when the inflammation of the peri-implant area
has reached the mucogingival line. To further reduce the bacterial load, one should proceed
with the mechanical therapy in the form of scaling and implant therapy equivalent to scaling

Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
 5

and root planing done in teeth but with a different approach [19]. In implants, since we have
the titanium surface to clean upon, so the materials used are to be softer than it. So, instead of
stainless steel, one can use plastic Teflon, carbon, gold-coated and titanium scalers and curettes.
If one is using ultrasonics, then, the tips should be covered with plastic PEEK
(Polyetheretherketone) and for polishing; there are rubber polishers, low-abrasion fluoride-free
and pumice-free prophylaxis paste or high-pressure jets of glycine particles [20].

The mechanical therapy used on the implant surface is optimal for removing soft deposits,
supragingival plaque and calculus along with free floating bacteria in the peri-implant sulcus.
But, with the formation of biofilm tightly adhered to the surface of the implant body, it is not
possible to completely eliminate the local deposits and microorganisms. So, in addition to
scaling, one can use adjunctive therapies in the form of antimicrobial mouthwashes such as
chlorhexidine and essential oils, submucosal irrigation with antiseptics and disinfectants such
as 10% povidine iodine, topical application of antibiotics in the form of local drug delivery
systems such as tetracycline fibres, sustained release of doxycycline, minocycline and use of
lasers or photodynamic therapy in the area concerned. Lastly, if the access to the peri-implant
area is inadequate, then one should remove the prosthetic superstructure and then proceed with
the therapy [21].

In cases of peri-implantitis, where there is bone loss in addition to soft tissue changes, non-
surgical therapy as described above is insufficient to resolve the infection. So, here one has to
resort to surgical methods to achieve desired results. The type and extent of peri-implantitis
also determines the surgical therapy to be executed. For early cases of peri-implantitis (i.e bone
loss <25% of the implant length), non-surgical therapy along with adjunctive use of antiseptics
and systemic antibiotics with regular follow-up of patients’s compliance can be a useful
treatment option. For moderate and advanced lesions of peri-implantitis (i.e bone loss 25 to
50% and >50% of the implant length), surgical therapeutical decisions are to be made
accordingly [22]. There are 3 to 4 general approaches to correct the peri-implant disease. One
can do an access surgery in the form of full-thickness flap elevation to access the implant
surface and then debridement of the surface and the bone defect [23].

Detoxification of the implant surface has to be done to achieve re-osseointegration of the

implant with the bone. For mechanical debridement, specially designed scalers are to be used.
For chemical cleaning, one has to decontaminate the surface with different chemicals such as
citric acid (40%), hydrogen peroxide, saline, tetracycline etc to decrease the bacterial load [24].
Although, these methods are effective in controlling the infection, yet, no mechanical or
chemical detoxification method can fully remove the biofilm form the surface and have proven
to be superior over the others. Another way to decontaminate the implant surface is by
Implantoplasty i.e elimination of the threads of the exposed part of the implant to reduce the
rough area and to achieve a smooth and polished surface [25]. Diamond burs are used to remove
Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
 6

the threads followed by ceramic and metal polishers that are applied for smoothening. In this,
one can stop the progressive bone loss although the major drawback of this technique is the
marginal recession of the tissues that can be unaesthetic especially in the anterior areas [26].
Therefore, if the peri-implant disease is concentrated to aesthetic areas with shallow bony
defects, then access therapy along with antiseptics, antibiotics and antimicrobials will be the
treatment of choice and if it is present in the area not esthetically important along with
suprabony component defects, then resective surgery along with apically positioned flap and
removal of soft and hard deposits on the implant surface is to be performed diligently. In this
way, probing pocket depths are also reduced and one section of the implant will be exposed for
assisting in patient’s hygiene. This is the second approach to stop and correct the peri-implant
infection. This treatment option is generally carried out along with implantoplasty to enhance
the results [27].

If the lesion around the implant is circumferential intrabony crater-like (also known as patellar
defect), then, the 3rd approach i.e regenerative surgery in the form of biomaterials, grafts, bone
substitutes along with barrier membranes are to be used to recover the lost bone tissue and
stabilize the implant. Although, there is no evidence of the superiority of a specific bone
grafting substitute in terms of long-term benefits, yet, whatever is used, there is approximately
maximum reduction of about 5 mm in pocket depth and 2 mm of bone filling with regenerative
therapy and if the patient compliance is good, then, one can expect good clinical results with
passage of time [28]. Last but not the least, the approach used in cases of advanced lesions of
peri-implant disease is explantation i.e implant removal. This can be done through various
implant removal kits, implant drivers, reverse screw devices and bone trephine systems. These
procedures are invasive in nature resulting in loss of soft and hard tissue around the implant
but if the prognosis is poor and feasibility of keeping the structure in the mouth is not
appropriate, then, it is better to explant the implant as soon as possible [29].

Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
 7

Figure 1: Decision tree/flow chart for diagnosing and treating peri-implant diseases.

Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
 8

Peri-Implant Mucosa and Maintenance Therapy

In any of the above given situations, it is generally said that a healthy masticatory mucosa of
about 2 mm around the implant offers protection against the bone loss and also improves the
aesthetic results in long-term [30]. Even though, many studies have pointed no difference in
prognosis for implants with good keratinized mucosa or not, still, it is better to have a good
surrounding mucosa for adequate oral hygiene levels and maintenance [23,31,32]. After the
placement, implant monitoring and supportive therapy is equally significant to improve the
results of the treatment done. Recall visits should be planned according to the patient’s risk
profile, clinical indices and the placement and design of the implant prosthesis. Based on the
presence of bleeding on probing, suppuration, biofilm, pocket depth and radiographic evidence
of bone loss, a systematic protocol as developed by Mombelli and Lang, known by the name
of Cumulative Interceptive Supportive Therapy (CIST) should be invoked and followed for the
implant survival [33]. Also, one can go along with the Peri-implant Index of Treatment Needs
(PIITN) as proposed by BuitragoVera PJ and Enrile De Rojas FJ, in 2016 that would facilitate
decision-making when there is requirement for any of the complications associated with peri-
implant health [21].

Conclusion

All said and done, there is no ideal situation where one can straight way follow and treat the
disease according to the guidelines. Many a times, there is a requirement of combined therapies
involving non-surgical, surgical and implantoplasty to prolong the life span of the implant
fixtures in the patient’s mouth. Nonetheless, as there is increased acceptance of the implants in
the dentistry all around, so, are the complications and problems associated with it. In the end,
we can say that, starting from diagnosis and pre-evaluation of the patient, every step is
important for achieving long lasting results and success. In any given state, right protocols
should be followed to curtail the peri-implant disease and if it occurs, it should be treated with
utmost priority and expertise based on the patient’s clinical scenario and the best option
possible for it. Reciprocating the facts, it can be stressed that routine monitoring and evaluation
of the implants at regular intervals can reduce the effects of risk factors associated with the
disease and will lead to favorable prognosis in the patient’s mouth.

Conflict of Interest

The authors report no conflict of interest. The authors alone are responsible for the content and
writing of the manuscript.

Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
 9

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Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302
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Kaur N | Volume 3; Issue 3 (2022) | JDHOR-3(3)-064 | Review Article

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases - An
Overview. J Dental Health Oral Res. 2022;3(3):1-10.

DOI: https://doi.org/10.46889/JDHOR.2022.3302