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Journal of Indian Society of Periodontology logoLink to Journal of Indian Society of Periodontology
. 2024 Jun 4;28(1):6–31. doi: 10.4103/jisp.jisp_124_24

Indian Society of Periodontology Good Clinical Practice Recommendations for Peri-implant Care

Anurag Satpathy 1, Vishakha Grover 1, Ashish Kumar 2, Ashish Jain 1,✉, Dharmarajan Gopalakrishnan 3, Harpreet Singh Grover 4, Abhay Kolte 5, Anil Melath 6, Manish Khatri 7, Nitin Dani 8, Roshani Thakur 9, Vaibhav Tiwari 10, Vikender Singh Yadav 11, Biju Thomas 12, Gurparkash Singh Chahal 13, Meenu Taneja Bhasin 14, Nymphea Pandit 15, Sandeep Anant Lawande 16, R G Shiva Manjunath 17, Surinder Sachdeva 18, Amit Bhardwaj 19, Avni Raju Pradeep 20, Ashish Sham Nichani 21, Baljeet Singh 22, P R Ganesh 23, Neeraj Chandrahas Deshpande 24, Saravanan Sampoornam Pape Reddy 25, Subash Chandra Raj 26
PMCID: PMC11232813  PMID: 38988964

Abstract

Current implant therapy is a frequently employed treatment for individuals who have lost teeth, as it offers functional and biological advantages over old prostheses. Concurrently, active exploration of intervention strategies aims to prevent the progression of peri-implant diseases and manage the existing peri-implant tissue damage. Indian Society of Periodontology has recognized the need for systematic documents to update the everyday clinical practice of general dental practitioners and has provided evidence-based consensus documents, namely good clinical practice recommendations from time to time to raise the oral health-related awareness and standards of oral health-care delivery across the country. The current clinical practice recommendations focused on peri-implant care to bridge the gap between academic theory and clinical practice by compiling evidence-based suggestions for preventing and treating peri-implant diseases. Twenty-eight subject experts across the country prepared these recommendations after a thorough literature review and group discussions. The document has been prepared in three sections covering peri-implant health and maintenance, peri-implant mucositis, and peri-implantitis. It will be a quick and concise reference for oral implant practitioners in patient management. The guidelines provide distinct definitions, signs, and symptoms, treatment required; recall visit specifications for plausible clinical case situations, and home-care recommendations regarding maintaining peri-implant health. The document advocates combined efforts of oral implant practitioners and the population at large with evidence-based, integrated, and comprehensive peri-implant care. By providing accessible, applicable guidance, these guidelines would empower dental professionals to uphold the well-being of implant patients and ensure the long-term success of implant therapy.

Keywords: Clinical guideline, dental implant, peri-implant diseases, peri-implant health, peri-implant mucositis, peri-implant osteitis, peri-implantitis

INTRODUCTION

Tooth loss is a common concern, leading to edentulous conditions and impaired patient function, such as aesthetics, mastication, and speech issues. Such problems embarrass the patient, and they seek tooth replacement. Over the past five decades, implant dentistry has transformed from an experimental procedure to a reliable choice for replacing lost teeth using implant-supported prostheses. Modern implant therapy is a commonly used treatment for patients with missing teeth due to its functional and biological benefits compared to traditional prostheses. Studies show success and survival rates exceeding 95% in the long term.[1-3]

Approximately 450,000 osseointegrated dental implants have been placed yearly in the last decade, with an expected 95% success rate, with minimum risks and associated complications.[4] Even the multiple replacements, including the implant-supported prosthesis, have generated quite a success rate. From 6.21B USD in 2022-6.86B USD in 2023, the worldwide dental implant market size increased at a compound annual growth rate (CAGR) of 10.5%. From 9.85 billion in 2027, this is projected to grow at a CAGR of 9.4%.[5] Due to rising incomes and economic stability, the Asia–Pacific area is expected to experience the quickest growth during the projected period. There is a growing burden of an aging population in many Asian countries due to their dense populations. A significant draw for medical tourists is the relative affordability of care in these nations. The dental implant market in India was worth 127.9 million US dollars in 2022. With a projected CAGR of 8.1% from 2023 to 2028, the market will reach US$ 205.2 million by 2028.[6]

The causative and risk factors of peri-implant diseases delve into the multifactorial aspects encompassing microbial biofilms, host response, and systemic health.[7] Furthermore, genetic and epigenetic factors have been reported to potentially influence individual susceptibility to peri-implant disease.[8] Concerted efforts have been made to standardize diagnostic criteria, ensuring research and clinical practice consistency. Moreover, advances in imaging techniques, including cone-beam computed tomography (CBCT), have significantly enhanced diagnostic accuracy.[9,10] Prevention strategies for peri-implant diseases mostly center on meticulous oral hygiene, regular maintenance, and patient education.[11] Concurrently, active exploration of early intervention strategies, encompassing nonsurgical approaches and antimicrobial agents, aims to halt the progression of peri-implant diseases.[12] For advanced cases with surgical regenerative techniques have been put forth.[13] Recent investigative efforts have been focused on understanding the impact of altering the implant surface as a treatment and its effectiveness.[14] It is essential to acknowledge the role of prosthodontic factors in peri-implant health, which include prosthetic design and fit. Finally, managing peri-implant disease through multidisciplinary collaboration among different dental specialties, such as periodontics, prosthodontics, and oral surgery, is crucial.

Prevalence of peri-implant diseases

It is essential to comprehend the epidemiology of peri-implant diseases to better understand its magnitude. Consequently, it is important to conduct cross-sectional field studies with suitable samples and clinical and radiographic data to investigate the prevalence and risk indicators of peri-implant diseases.

Previous studies have reported a wide range of prevalence of peri-implantitis from 14.38 to 24.27%.[7] Retrospective investigations, such as the one conducted by Fransson et al. in 2005,[15] have indicated a high prevalence of inflammatory responses in peri-implant tissues, with 90% showing peri-implant tissue inflammation. In addition, their studies found a 28% prevalence of peri-implantitis. Roos-Jansaker et al.[16] found that almost 48% of cases in their study had peri-implant mucositis (PIM), and 6.6% had peri-implantitis. Recent research, such as the one conducted by Rodrigo et al.,[17] indicates a prevalence of 51% of peri-implant disease in the Spanish population.

The reported variability may be influenced by various factors, such as the duration of follow-up or the disease’s definition. The 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions proposed a new way to categorize these diseases.[18] However, ever since, there have been several aspersions on its acceptance. The wide variations in the prevalence data can also be attributed to differences in the case definitions used in various studies, such as the extent of supporting bone loss, probing depth, the diversity of groups studied, and the specific risk factors present in each population.

WHAT IS THE LEVEL OF KNOWLEDGE AND PRACTICE TRENDS WITH RESPECT TO PERI-IMPLANT HEALTH AND DISEASE IN INDIA?

An online survey conducted among the dental practitioners of India within the purview of this consensus document revealed a general lack of knowledge about the periodontal health and disease. While 75.8% of the respondents could correctly identify the diagnostic criteria for peri-implant health, 63.7% could correctly recognize the diagnostic criteria for PIM, and only 39.6% could do the same for peri-implantitis, respectively. Around 15% of the respondents did not measure the probing depth, and 36.3% relied only on a single radiograph to diagnose peri-implantitis. The lack of knowledge about peri-implant diseases has also been reported previously among medical professionals in Himachal Pradesh.[19] A similar survey among dental practitioners of Hyderabad city revealed that there was a lack of understanding about recall visits and etiological factors among the self-trained and those trained through the internet.[20] A recent questionnaire survey among dental students of Jharkhand reported that 47.8% of students were moderately well-informed about dental implants, and most of them lacked knowledge about the etiology and clinical features of peri-implant disease.[21]

IS IT NECESSARY TO DEVELOP CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF PERI-IMPLANT DISEASES?

There have been several clinical practice guidelines that have been put forth, which have been instrumental in serving as a guide path in the clinical practice of oral implantology [Table 1].[12,18,22-34] However, very few among them have dealt with practicality of the disease management and its maintenance. In addition, quite variability has been observed in terms of case and clinical definition of peri-implant conditions (PIC). Furthermore, the guidelines have often maintained an academic tone, which makes it difficult for the general dental surgeon to adapt and implement.

Table 1.

Clinical practice guidelines/consensus reports on peri-implant diseases over the years

Year Society/Association Topic/Theme
2007 The ICOI Pisa Consensus Conference Implant success, survival, and failure[22]
2008 European Workshop on Periodontology Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology[23]
2011 European Workshop on Periodontology Peri-implant diseases: Where are we now?-Consensus of the Seventh European Workshop on Periodontology[24]
2013 The ITI Prevention and Management of Biologic and Technical Complications- Therapy of PI - Consensus Statements[25]
2016 Baltic Osseointegration Academy - The 1st Baltic Osseointegration Academy and Lithuanian University of Health Sciences Consensus Conference Summary and Consensus Statements: Group II – PI Diagnostics and Decision Tree[26]
2016 American College of Prosthodontists Clinical Practice Guidelines for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental Restorations[27]
2019 FDI Peri-implant Diseases Project and Consensus Workshop - ICOI General genetic and acquired risk factors, and prevalence of peri-implant diseases - Consensus report of working group 1[28]
2019 FDI Peri-implant Diseases Project and Consensus Workshop - ICOI Local risk indicators - Consensus report of working group 2[29]
2019 FDI Peri-implant Diseases Project and Consensus Workshop - ICOI Diagnosis and nonsurgical treatment of peri-implant diseases and maintenance care of patients with dental implants - Consensus report of working group 3[30]
2019 FDI Peri-implant Diseases Project and Consensus Workshop - ICOI Surgical treatment of PI - Consensus report of working group 4[31]
2018 American Academy of Periodontology and the European Federation of Periodontology 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[18]
2020 15th European Consensus Conference Update PI - peri-implant inflammation and peri-implant disease[32]
2021 The 6th EAO Consensus Conference 2021 Peri-implantitis: Summary and consensus statements of group 3. The 6th EAO Consensus Conference 2021[12]
2022 The ITI; Proceedings of the 6th ITI Consensus Conference held in Amsterdam in 2018 ITI Treatment Guide Volume 13 - Prevention and Management of Peri-Implant Diseases[33]
2023 European Federation of Periodontology Prevention and treatment of peri-implant diseases—The EFP S3 level clinical practice guideline[34]
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ICOI – International Congress of Oral Implantologists; ITI – International Team for Implantology; PI – Peri-implantitis; EFP – European federation of Periodontology ; EAO – European Association for Osseointegration; FDI – FDI World Dental Federation

Therefore, there is a need to establish applicable good clinical practice recommendations (GCPR) for the identification and management of PIC. These suggestions seek to identify best-practice strategies for protecting the health of peri-implant tissues, hence increasing the complication-free survival of dental implants used to replace missing teeth. In so doing, this guideline aims to:

  1. Improve peri-implant disease management using informed preventive/therapeutic methods, leading to global higher-quality therapies

  2. Minimize dental implant loss owing to peri-implant disease

  3. Improve patient quality of life.

The document, an Indian Society of Periodontology (ISP) initiative, plans to compile a list of the best evidence-based suggestions for each type of intervention used to manage (both avoid and treat) peri-implant diseases based on the evidence that is currently available and/or the expert consensus. The document will not only bridge the gap between academics and practitioners, but also will be essential for training and imparting knowledge to every oral health-care professional and stakeholder related to dental implant rehabilitation in academic institutions, hospitals, and community-based dental clinics.

Section I of the document focuses on peri-implant health, outlining the fundamental principles and considerations surrounding the maintenance of optimal conditions around dental implants and risk factors for peri-implant diseases. It delves into aspects such as proper oral hygiene practices, regular professional examinations, patient education, and home-care instructions to uphold the well-being of the implant and surrounding tissues. Section II focuses on PIM, discussing the early inflammatory condition affecting the soft tissues surrounding implants. It explores the etiology, diagnosis, and management strategies to prevent its progression into more severe complications. Section III addresses peri-implantitis and other PIC, delving into the inflammatory and noninflammatory processes and treatment modalities for this more advanced and potentially destructive condition affecting dental implants. This section aims to provide a comprehensive understanding of the various peri-implant complications and their management to ensure the long-term success of implant therapy.

SECTION I: PERI-IMPLANT HEALTH AND MAINTENANCE

What do we understand by the term peri-implant health?

Peri-implant health refers to the state of well-being of the tissues surrounding dental implants. Specifically, it involves the maintenance of a stable and healthy state of peri-implant tissues. Functionally, the peri-implant mucosa protects the underlying bone, while the alveolar bone supports the implant.

Peri-implant health may be objectively described by the absence of erythema or swelling, no bleeding or suppuration on gentle probing, a stable probing depth, and an absence of bone loss ≥2 mm one year after the prosthetic load.

When the peri-implant mucosa is healthy, it is about 3–4 mm and has either a keratinized (masticatory mucosa) or a nonkeratinized epithelium (lining mucosa) covering it. This mucosa has a connective tissue core composed primarily of collagen fibers and matrix elements. It has a “coronal” part, which is lined by a sulcular epithelium and a thin junctional epithelium, as well as a larger “apical” part which is in direct contact with the implant surface [Figure 1]. The majority of the implant’s intrabony part is in contact with mineralized bone, with the remainder exposed to bone marrow, vascular structures, or fibrous tissue.

Figure 1.

Figure 1

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Implant– tissue interface

The oral environment continually challenges the peri-implant tissues and its adherence (seal) with microorganisms in the plaque biofilm which accumulate on the tooth and implant surfaces. The typical peri-implant mucosa pronounces a host response, involving vascular and cellular processes. This results in the appearance of discrete vascular structures in the connective tissue lateral to the epithelium. In addition, tiny clusters of inflammatory cells are found throughout the interface zone, but polymorphonuclear leukocytes are concentrated in the connective tissue immediately lateral to the epithelium.

Clinically, the state of peri-implant health is ascertained through a comprehensive examination such as probing depth, bleeding on probing (BoP), absence of inflammation, and stability of the implant-supported prosthesis.[35] The interproximal sites of an implant may be intricately linked to the integrity of the soft and hard tissues at the implant interface. In the absence of pathology, histological assessments should reveal well-adapted soft-tissue integration, a lack of inflammatory infiltration, and maintenance of the peri-implant crestal bone.[18]

What disrupts peri-implant health?

Dental implants are susceptible to the colonization of microorganisms, including bacteria, within the oral environment. Plaque biofilm, a complex matrix of bacteria and extracellular polymeric substances adheres to implant surfaces, initiating an inflammatory response in the surrounding tissues.[36] If left unchecked, this inflammatory reaction can progress to peri-implant diseases, characterized by the destruction of supporting structures and potential implant failure.[37] PIM occurs when inflammation affects the peri-implant mucosa. The untreated PIM may extend to deeper supporting structures resulting in peri-implantitis.

What are the risk factors for peri-implant disease? How can we help educate people regarding risk factor reduction?

When it comes to peri-implant illness, posttreatment healing, and the maintenance phase, risk factors are crucial. Reducing risk factors is crucial for controlling peri-implant illness, and identifying them allows for patient-specific prevention and specialized therapy. A crucial part of caring for patients with dental implants is educating them on how to control these risk factors [Figure 2]. Therefore, in modern dental best practice settings, patients undergoing dental implant rehabilitation must be aware of, and able to modify and control, any risk factors that may affect their health and overall well-being. The two main goals of peri-implant health promotion and disease prevention are: (i) raising public awareness of the importance of peri-implant health and its promotion and (ii) improving access to peri-implant care, which requires a coordinated effort. This can be accomplished through the utilization of print, Internet, and social media channels, as well as the distribution of picture posters and pamphlets, to raise community awareness of peri-implant diseases.

Figure 2.

Figure 2

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Risk factors for peri-implant diseases

Local risk factors

  1. History of periodontal disease: Individuals who have already had periodontitis have an increased susceptibility to developing peri-implant disease. Prior treatment and ongoing maintenance of periodontal health are essential. Patients with a previous occurrence of periodontitis had a higher occurrence of peri-implant disease when their overall plaque score was elevated. Patients diagnosed with periodontitis exhibited a 2.29 times greater likelihood of developing peri-implantitis compared to patients without periodontitis[38,39]

  2. Poor oral hygiene: Poor oral hygiene is a significant risk factor for peri-implant diseases. There is significant evidence suggesting that bacterial biofilms play a pivotal role in the progression and development of peri-implant diseases.[18] Investigations on self-performed plaque control have demonstrated a significant correlation between poor plaque control and the development of peri-implant disease.[7,11,12] Preventive intervention in improving oral hygiene behaviors with specifically tailored oral hygiene instructions can reduce the risk of peri-implant disease[40]

  3. Peri-implant mucosal seal: The integrity of the peri-implant mucosal seal is crucial for preventing microbial ingress and subsequent inflammation. Poorly adapted restorations and residual cement have been identified as potential risk factors.[41] Incomplete cement removal in the peri-implant area can cause irritation, an environment for bacterial attachment and inflammation. It can also act as a barrier to access the subgingival space[42,43]

  4. Available bone: Nonaugmented bone is associated with a better prognosis. In addition, there is a lower risk in the maxilla than in the mandible. Further, an adequate and vascularized bone favors peri-implant health[44]

  5. Biomechanical overload: Excessive occlusal forces and unfavorable biomechanics can lead to micromotion at the implant-bone interface, triggering peri-implant bone loss.[45]

  6. Keratinized mucosa and tissue biotype: A peri-implant width of keratinized mucosa <2 mm is associated with increased plaque accumulation and more discomfort after tooth brushing. Thereby may be associated with peri-implant disease.[46-48] Furthermore, those with a thin biotype may be more susceptible to experiencing a greater severity of the condition[49-51]

  7. Implant sulcus depth: The soft-tissue cuff around the implant exhibits less resistance when it is compared to the adjacent teeth sulcus.[52] The peri-implant mucosa forms a protective barrier around the transmucosal part of the implant, abutment, or repair to maintain clinical health. Initial probing depth is modulated by the height of the soft tissue surrounding the implant after insertion. In general, the probing depth associated with peri-implant health should be <5.5 mm.[35] When the peri-implant probing depth increases, inflammatory signs and biofilms at the sulcus are evident. Several studies[7,12,47,53-55] have reported in favor of probing depth having a positive predictive value, indicating that a relative increase in implant sulcus depth influences the onset of peri-implant disease

  8. Titanium particles: The presence of titanium (Ti) particles in peri-implant tissue is increasingly being discussed as the cause of peri-implant disease.[56-59] It seems that implants with platform switches show less tribocorrosion.[60]

Systemic and patient-related risk factors

  1. Diabetes mellitus: It is an established risk factor for peri-implantitis. Several studies[61,62] suggest that high glycemic levels will be a risk factor for peri-implant disease. People with diabetes who are experiencing glycometabolic decompensation are more likely to bleed when the implant is probed and lose bone around it.[63] This is especially true for people with badly controlled diabetes mellitus whose hemoglobin A1C is above 8% and who have deeper probing, bleeding during probing, and bone loss around the implant.[64,65] Glycemic control is recommended for maintaining peri-implant health[66]

  2. Osteoporosis: Diminished bone density associated with osteoporosis contributes to compromised implant stability and an increased susceptibility to peri-implant bone loss[67,68]

  3. Smoking: Tobacco smoking seems to be associated with tissue changes and bacterial alterations.[69,70] A direct relationship exists between smoking and prevalence of peri-implant disease.[71] Smokers had a 2.7–31 times increased chance of developing peri-implant diseases.[72,73] A validated smoking cessation intervention will reduce the risk of peri-implant disease[40]

  4. Radiation therapy: It has been reported as a significant risk factor for peri-implant disease.[74] The survival rates of dental implants may be affected adversely by radiotherapy. It has been reported that maxillary sites, bone substitutes, and higher radiation doses are adverse prognostic factors.[75]

Metabolic syndrome, low Vitamin D levels, high-serum alkaline phosphatase levels, bisphosphonate therapy, chemotherapy, and immunosuppression are some other things that could be potential threats. Further, by comprehending the crucial elements linked to the onset of peri-implant illnesses, the dental implant practitioner can strategically target these aspects to enhance the results of implant therapy by taking steps to modify the risk as best as possible. For this, they may utilize an online tool; “The Implant Disease Risk Assessment (IDRA).”[76]

How do we go about the assessment of peri-implant tissues?

The experts firmly agreed that objective screening protocols for peri-implant health and disease in dental clinics are currently nonexistent in India. A simple, consistent, and user-friendly method of patient screening is required. The following simple and practical approach for the assessment of peri-implant tissues can be followed in day-to-day dental implant practice.

Clinical assessment

  1. Oral hygiene: Oral hygiene, in general, should be recorded as part of the clinical evaluation of the soft tissue surrounding implants, with an emphasis on the presence of biofilm on implants and their restorations.[77] In addition, the presence or absence of food debris should be noted[78]

  2. Visual examination of peri-implant mucosa: Inspection of the peri-implant mucosa for color change, swelling, glazing, enlargement, mucosal recession or ulceration, and pus discharge should be done[79]

  3. Peri-implant keratinized mucosa: Peri-implant keratinised mucosal width can be measured as the distance between the crest of peri-implant mucosal margin and the mucogingival junction.[80] To enhance the visibility of the border between keratinized and nonkeratinized mucosa, iodine solution can be used on the mucosa if needed

  4. Peri-implant probing: Probing peri-implant tissues is essential for diagnosing peri-implant disease and requires astute clinical skill, and methodological precision, particularly when utilizing a periodontal probe [Figure 3].[81]

    Compared to probing around the natural teeth, probing around there is a large discrepancy between the implant diameter and the crown size. Despite that, probing gives a fair idea of the topography of the tissues around the tooth or implant. The probing depth is measured from a fixed reference point on the implant or the prosthesis. It may be challenging to record the exact probing depths around implants because of surface treatment, concavities, or steps in the design[82]

    1. Probe selection: Accurate measurements around dental implants begin with selecting the right periodontal probe. The best probes are thin and light to avoid damaging the implant site, often composed of Ti, plastic, or teflon-coated material. The WHO probe is suggested to be used to ease the examination for day-to-day use by dental implant practitioners [Figure 4]. Its importance has been well documented previously in the ISP GCPR-gum care document.[83] Using the WHO probe shall help the clinician to detect the presence of peri-implant health and disease areas effortlessly, accurately, and quickly
    2. Patient preparation: Topical anesthesia might be given before probing to make the process more comfortable for the patient. To promote cooperation and reduce apprehension, informing the patient about the noninvasive nature of probing and its significance in monitoring peri-implant health is essential[53]
    3. Probing depth (PD): Precise technique and careful handling are required for probing depth measurement. Carefully place the periodontal probe into the peri-implant sulcus in a straight line with the implant’s long axis; angulation can cause erroneous measurements.[84] A gentle force (around 0.25 N) should be used using the walking method while probing.[23] The depth of the peri-implant sulcus should generally be <5.5 mm. 3.5–5.5 without inflammation are at an increased risk of breakdown and development of peri-implant disease
    4. Bleeding on probing: The probe is gently walked along the sulcus, and any observed bleeding within 30s of PD measurement is noted. BoP is an early indicator of potential peri-implant disease and aids in targeted interventions.[53] Implant sites that have been determined to be healthy should not have bleeding while probing
    5. Suppuration on probing (SoP): The probe is gently walked along the sulcus, and any observed suppuration (SUP) while PD measurement is noted as present or absent. Clinical studies on the signs of peri-implant disease have shown that SUP is likely to present when the bone loss is getting worse and there is peri-implant pathology.[11,85]

  5. Implant mobility:[86] This can be assessed either by a conventional method using two rigid instruments employing the implant mobility scale,[87] or using the automated devices (Periotest® [Siemens AG, Bensheim, Germany], OsstellTM [Integration Diagnostices Ltd., Goteborgsvagen, Sweden])

  6. Occlusal evaluation: Implant occlusion is an essential and quite an extensive area of discussion. Detailed discussion on implant occlusion is beyond the scope of the present document. Briefly, the evaluation of any deflective or premature contacts and parafunctional habits should be recorded.[88,89]

Figure 3.

Figure 3

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Peri-implant probing

Figure 4.

Figure 4

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Markings on a WHO probe. mm - millimeter

Radiographic assessment

The radiographic assessment protocol after dental implant placement is a systematic and dynamic process. Recent incorporation of advanced imaging techniques and implant-specific considerations to comprehensively understand peri-implant health. A comprehensive assessment, combining clinical and radiographic parameters, is essential for early detection and effective management of peri-implant disease.[90]

  1. Postoperative radiograph: Radiographic assessment with baseline images immediately after implant placement is suggested. Periapical/vertical bitewing radiographs (preferably using a parallel cone technique and a rigid film-object X-ray source coupled to a beam-aiming device to achieve reproducible exposure geometry),[91] panoramic radiographs, or CBCT can be employed to capture detailed views of the implant position, adjacent structures, and initial bone levels[92,93]

  2. Baseline radiograph: Radiographic assessment after 1 year after the functional loading (prosthetic restoration) when the initial remodeling is expected to be completed,[94] with clear visualization of implant threads and mesial and distal bone levels should be essential for future comparisons.[95]

Subsequently, a comparative assessment of marginal bone levels should be done with sequential radiographs (periapical/vertical bitewing radiographs/CBCT scans) taken periodically to measure the distance from the implant-abutment junction to the alveolar crestal bone [Figure 5]. There should not be any more bone loss beyond what the initial remodeling produces at the bone’s level which is 2 mm.[96] Changes of 2 mm or more at any time after the 1st year or later should be considered pathogenic.[81,97]

Figure 5.

Figure 5

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Radiographic assessment of the peri-implant bone level

Is there any requirement for intervention in individuals with prevailing peri-implant health?

Even when individuals exhibit overall peri-implant health, the presence of local deposits such are dental plaque and calculus around the implant prosthesis or other teeth can pose a significant risk to the stability and longevity of the implants. These deposits can harbor harmful bacteria, leading to inflammation, infection, and potential disruption of peri-implant health. Therefore, regular cleaning appointments are essential for individuals with dental implants, even if they currently exhibit peri-implant health. Professional mechanical debridement, a nonsurgical dental procedure, is an effective means to address the accumulation of plaque and calculus around dental implants.

PERI-IMPLANT MAINTENANCE

What is the rationale for a follow-up regimen for peri-implant maintenance care?

Peri-implant health can be affected by microbial biofilm in individuals who are susceptible. Therefore, it is necessary to regularly eliminate the microbial plaque biofilm by professional and self-performed plaque removal for optimal long-term outcomes. The number of people whose dental implants failed was reduced by 90% for those who got regular care compared to those who did not. Furthermore, patients who get regular maintenance care are much less likely to experience bone loss around their implant.[98,99]

The chance of getting peri-implantitis was found to be 3.7% in the group that had professional peri-implant maintenance care (PIMC) every 4 months, compared to 22.7% in the group that did not receive PIMC, according to a 12-month comparative study.[100] A long-term evaluation found that 8.5% of patients with biannual visits had peri-implantitis at the implant level, compared to 9.3% of those with annual visits (>6 months) who adhered slightly more frequently.[101] In addition, a recent comprehensive analysis found that reducing the patient-level incidence of peri-implantitis from 36.5% to 12.5% requires administering PIMC interventions at least twice yearly.[102,103]

Unfortunately, there is a lack of clear guidelines for maintaining the health of implant restorations and supporting tissues, and current methods are frequently based on patients with natural teeth. To reduce the likelihood of restoration failure, peri-implant disease, and implant failure, maintenance recommendations for patients with implant-borne removable and/or fixed restorations are essential.

What protocol should be followed during peri-implant maintenance care visits?

Maintaining peri-implant health is crucial for the long-term success of dental implants. The aim is to monitor healing, assess peri-implant tissues, and provide personalized care to prevent potential complications.

Review (what to ask)

  1. Thorough medical and dental history: Start by going over the patient’s entire medical and dental history in detail, paying close attention to any changes that have occurred since the last appointment such as current data on drugs, lifestyle variables, and systemic problems

  2. Patient concerns and experiences: Engage in open communication to address any concerns or experiences the patient may have had since the last appointment. Encourage patients to share details about their oral hygiene routine and any discomfort they might be experiencing.[104]

Examination (what to see/look for)

  1. Peri-implant tissue assessment: Conduct a detailed assessment of the peri-implant soft tissues, checking for signs of inflammation, redness, swelling, or bleeding/pus discharge on probing (refer to assessment of peri-implant tissue)

  2. Radiographic assessment: Perform a radiographic assessment to evaluate peri-implant bone levels. Utilize periapical or panoramic radiographs as needed (refer to radiographic assessment)

  3. 3.Prosthetic assessment: Examine the stability and integrity of the implant-supported prosthesis. Check for any signs of loosening, fractures, or complications related to the prosthetic components

  4. Occlusal examination:[105,106] Evaluate the occlusion to ensure proper function and detect any signs of occlusal overload. Address any discrepancies in occlusion to prevent biomechanical complications. Shimstock is the optimal method for assessing occlusion on implant crowns. Instruct the patient to bite on the shim stock with the implant prosthesis and apply pressure to assess occlusal contact. Next, repeat the process for the neighboring natural teeth. Seek light touch on the implant crown where the shimstock tugs through easily, and solid contact on the surrounding teeth where the shimstock gets trapped or tears. This suggests that the forces are evenly distributed and not focused on the implant. You can also use articulating paper, but the results might be inaccurate if you depend on its thickness. Mark using the thinnest paper you can find. It may be necessary to re-balance the occlusion to reduce the pressure on the implant if you see heavy occlusion on the implant but light on the neighboring teeth

  5. Adequacy of oral hygiene access: Assess the patient’s ability to maintain optimal oral hygiene around the prosthesis. Evaluate the accessibility of the restoration for effective cleaning and provide instructions if modifications are necessary.

Work plan: (what to do)

  1. Individualized oral hygiene instructions: Provide personalized oral hygiene instruction based on the patient’s specific needs and challenges. Emphasize the importance of proper brushing, flossing, and the use of adjunctive tools for implant hygiene

  2. Demonstration of home care techniques: Demonstrate effective cleaning techniques and recommend suitable oral hygiene products. Consider providing educational materials or videos to reinforce the importance of maintaining optimal oral health

  3. Customized treatment plan: Based on the assessment, develop a customized treatment plan addressing any identified issues. This may include adjustments to the occlusion, prosthetic components, or recommendations for further professional interventions

  4. Schedule follow-up appointments (refer to peri-implant maintenance care recall): Determine an appropriate follow-up schedule based on the patient’s needs and risk factors. Schedule regular recall appointments to monitor peri-implant health and intervene promptly if any complications arise.

What should be the peri-implant maintenance recall protocol

The frequency and interval of maintenance care or recall visits can vary depending on several factors, including the patient’s oral health status, tissue abuse habits, and systemic health. It is quite understandable that a more complicated case would require a more frequent interval. The expert panel recommends the peri-implant care recall intervals based on the peri-implant probing depth after the treatment endpoints have been achieved in Table 2.

Table 2.

Peri-implant care recall interval

Peri-implant PD (mm) 1st year after prosthetic loading (months) 2nd year onwards Presence of co-existing periodontal disease (months) Current smoker HbA1c >6.5
PD <3.5 6 1 year 3 Reduced by 1 month Reduced by 1 month
PD 3.5–5.5 3 6 months 3
PD >5.5 3 3 months 3
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PD – Probing depth; HbA1c – Glycated haemoglobin

What should be the in-office and home peri-implant care regimen

In-office peri-implant care

When choosing instruments for implant maintenance, you need to think about things like how light they are, whether they are disposable or sterilizable, how well they remove plaque without damaging the implant surface, how cheap they are, how easy they are to use, and how they can be adjusted within the implant sulcus. Modalities of in-office implant care may be the following:

  1. Mechanical debridement: The approach avoids using metallic instruments at the implant-abutment contact because they are prone to causing abrasions, contamination, and galvanic responses. In cases when manual scalers are impractical for implant prostheses, sonic or ultrasonic scalers with nylon or plastic tips strengthened with graphite are recommended.[41] To reduce the possibility of unintended peri-implant tissue damage, use short strokes with mild pressure, tailored to the exact areas of deposit buildup. Other biofilm removal approaches include using air-abrasive glycine powder along with instrumentation with plastic curettes and a subsequent intrasulcular irrigation with a 0.1% chlorhexidine solution.[107] Recent advances include the use of a chitosan brush for debridement of peri-implant surfaces[108]

  2. Polishing:[104] The use of nonabrasive polishing pastes, such as aluminum oxide, tin oxide, appropriate prophy paste, and low abrasive dentifrice, is recommended for polishing purposes[86]

  3. Local chemotherapeutic agents:[109] Plastic irrigation tip may be used to introduce antiseptic agents such as chlorhexidine gluconate or povidone-iodine to the base of the implant sulcus. Minocycline, azithromycin, tetracycline, amoxicillin, doxycycline, and metronidazole are local/topical antibiotics that may enhance the effectiveness of the definitive treatment for the condition. However, their usage in clinical practice is limited due to the absence of decisive evidence.

Home peri-implant care

After successful osseointegration of the implant has been confirmed, it is essential to establish a thorough home oral hygiene routine. Research in this field is scarce and has yet to establish a universally accepted protocol for implant maintenance. Current recommendations are primarily drawn from expert opinions, studies on natural teeth, and clinical experience. However, following consensus discussions, the expert panel has proposed a consolidated approach called the “@Home Implant Care Regimen” for maintaining implant health, which emphasizes the concurrent use of dentifrices, powered toothbrushes, and oral irrigators. Only those home peri-implant care products that will not change the implant abutment surface and are also safe and efficient for routine use should be used and advocated by following a home implant care regimen [Figure 6].[110]

Figure 6.

Figure 6

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Home implant care regimen. (a) Toothbrushing, (b) Water flossing and, (c) Mouth rinsing

  1. Tooth brushing: The implementation of “Anchor Free Tufting Technology (AFT)” represents a recent breakthrough in toothbrush engineering, providing enhanced flexibility in hole dimensions, bristle density, variety of shapes, and trimming profiles. This innovation has been integrated into the Colgate PerioGard© Gum Expert toothbrush by Colgate [Figure 7], featuring multi-height bristles, slender tufts on both sides and densely packed ultra-slim bristles. These improvements enable better conformity and accessibility of the toothbrush to the tooth-gingival junction, resulting in enhanced cleaning effectiveness. In particular, toothpaste formulations such as Colgate PerioGard©, which include a combination of antimicrobial agents such as zinc and pyrophosphate, play a beneficial role in minimizing the accumulation of soft and hard deposits on the implant surface. This reduces the likelihood of biofilm-related infections and inflammation around the implant sites.[111] Furthermore, an electric toothbrush equipped with a tapered brush can access the undersides of connection bars and aid in interdental cleaning.[110] The use of small, soft-bristled brushes in a circular motion is recommended. In addition, toothbrush heads with end tufted brushes or narrow rotary brushes can be useful for reaching unreachable areas. An end-tufted brush is useful in hard-to-reach areas, especially in the posterior areas.[104] Further, using a good technique while using the electronic toothbrush is imperative

  2. Water flosser/irrigation: Tooth brushing cannot reach every part of the mouth. Also, there is a general lack of skill to use dental floss. A water flosser enables an easy and effective cleaning around implants while promoting healthy gums. Mahajani et al.[112] and Almoharib et al.[113] demonstrated that the use of water flossers was associated with much less bleeding than that of string floss around implants. Water flossers with greater power setting can dislodge food particles and debris without causing harm to the implant or the surrounding gum tissue. The Colgate Blast© is a cordless, portable, and rechargeable oral irrigator that operates at 1600 pulsations per minute and offers three adjustable pressure modes: gentle, regular, and pulse, along with a nozzle size of 0.55 mm [Figure 8]. This design creates a flushing zone capable of expelling debris and bacteria from the sulcus or pocket around an implant, utilizing a thin line of water flow, and is reported to be three times more effective than devices with a continuous-stream mechanism

    • For effective use: Fill the water reservoir of the water flosser and modify the settings to prepare it for use. It is recommended to commence with a lower pressure setting on most water flossers and progressively raise it as one acclimates to the sensation. Patients should lean over the washbasin to begin to prevent water from spilling. After inserting the water flosser tip into the mouth and closing the jaws to prevent splashing, device is activated. The water flosser jet should be aimed at the implant prosthesis and gumline at a 45° angle. Gradually maneuver the flosser tip along the gumline, pausing momentarily between the implant fixtures and teeth in the vicinity.
Figure 7.

Figure 7

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Anchor free tufting technology utilized in gum expert tooth brush design (Courtesy: Colgate-Palmolive, India)

Figure 8.

Figure 8

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A portable water flosser with 1600 ppm and 3 pressure setting modes i.e. gentle (37–68 psi), regular (42–92 psi) and pulse (27–60) (Courtesy: Colgate-Palmolive, India). ppm - pulsations per minute; psi - pound-force per square inch

Antimicrobial mouthrinse

The incorporation of antimicrobial rinses into the home peri-care regimen serves as a valuable adjunct to promote optimal peri-implant health. Antimicrobial agents, such as chlorhexidine[114] or essential oils, exhibit bactericidal properties, effectively mitigating microbial colonization and reducing the risk of peri-implant diseases. Clinical studies have reported plaque reductions of 45%–61% and, more importantly, gingivitis reductions of 27%–67% with Colgate Periogard© containing 0.12% aqueous solution of chlorhexidine digluconate.[32-34,107,114] Patients are encouraged to use these rinses as directed by their periodontal care provider, ensuring a systematic approach to targeting potential pathogenic microorganisms. This adjunctive measure aids in controlling biofilm accumulation around implant surfaces, thereby contributing to the prevention of inflammation and maintaining the long-term stability of dental implants.

Peri-implant care in different types of implant-borne restorations (removable and fixed) would require customized professional (in-office) and home care regimen depending on the type of restoration for long-term success. A summary of recommendations is provided in Table 3.

Table 3.

Peri-implant care recommendations in removable and fixed implant-borne restorations (Adapted from Bidra et al.)[27]

Prosthesis Type Instructions
In-Office Peri-implant Care
 General Instructions Perform extraoral and intraoral examination, oral hygiene instructions, and oral hygiene intervention (cleaning of any natural teeth, tooth-supported restorations, implant-supported restorations, or implant abutments).
 Implant-supported Removal Prosthesis Perform a detailed examination of the prosthesis, intra and extraoral prosthetic components, and patient education of foreseeable problems that could impair the optimal function of the restoration.
Adjust/repair/replace prostheses that could impair patients’ optimal hygiene and function.
 Implant-supported Fixed Prosthesis Only use instruments compatible with the implant type and material, abutments, and restorations, (Glycine powder air polishing system may be used)
If required, the prosthesis should be removed to clean, and prosthesis contours should be reassessed to facilitate at-home maintenance.
Perform an examination of the prosthesis and components for any foreseeable problems.
Adjust/repair/replace prostheses that could impair patients’ optimal hygiene and function.
Consider using new prosthetic screws when an implant-supported restoration is removed for professional mechanical maintenance.
Judicious use of localised antimicrobial lavage with short-term use of chlorhexidine gluconate when indicated.
For coronal polishing around implants use a soft rubber tip, not a brush, with a nonabrasive paste.
Home Peri-implant Care
 Implant-supported Removal Prosthesis Brush existing natural teeth and restorations twice daily and the use of oral hygiene aids such as dental floss, water flossers, and electric toothbrushes.
Clean prosthesis at least twice daily using a soft brush with a professionally recommended denture-cleaning agent.
Remove the restoration while sleeping. The removed prosthesis should be stored in a prescribed cleaning solution.
 Implant-supported Fixed Prosthesis Brush twice daily and using oral hygiene aids such as dental floss, water flossers, air flossers, interdental cleaners, and electric toothbrushes.
Advise to use oral topical agents such as toothpaste containing 0.3% triclosan and to add supplemental short-term use of chlorhexidine gluconate when indicated.
For those using occlusal devices should be educated to wear the occlusal device during sleep.
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  94. Galindo-Moreno P, León-Cano A, Ortega-Oller I, Monje A, O Valle F, Catena A. Marginal bone loss as success criterion in implant dentistry: Beyond 2 mm. Clin Oral Implants Res 2015;26:e28-34.

  95. Borgonovo AE, Censi R, Vavassori V, Dolci M, Calvo-Guirado JL, Delgado Ruiz RA, et al. Evaluation of the success criteria for zirconia dental implants: A four-year clinical and radiological study. Int J Dent 2013;2013:463073.

  96. de Souza JG, Neto AR, Filho GS, Dalago HR, de Souza Júnior JM, Bianchini MA. Impact of local and systemic factors on additional peri-implant bone loss. Quintessence Int 2013;44:415-24.

  97. Sordi MB, Perrotti V, Iaculli F, Pereira KC, Magini RS, Renvert S, et al. Multivariate analysis of the influence of peri-implant clinical parameters and local factors on radiographic bone loss in the posterior maxilla: A retrospective study on 277 dental implants. Clin Oral Investig 2021;25:3441-51.

  98. Costa FO, Takenaka-Martinez S, Cota LO, Ferreira SD, Silva GL, Costa JE. Peri-implant disease in subjects with and without preventive maintenance: A 5-year follow-up. J Clin Periodontol 2012;39:173-81.

  99. De la Rosa M, Rodríguez A, Sierra K, Mendoza G, Chambrone L. Predictors of peri-implant bone loss during long-term maintenance of patients treated with 10-mm implants and single crown restorations. Int J Oral Maxillofac Implants 2013;28:798-802.

  100. Aguirre-Zorzano LA, Vallejo-Aisa FJ, Estefanía-Fresco R. Supportive periodontal therapy and periodontal biotype as prognostic factors in implants placed in patients with a history of periodontitis. Med Oral Patol Oral Cir Bucal 2013;18:e786-92.

  101. Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects. J Clin Periodontol 2006;33:929-35.

  102. Monje A, Aranda L, Diaz KT, Alarcón MA, Bagramian RA, Wang HL, et al. Impact of maintenance therapy for the prevention of peri-implant diseases: A systematic review and meta-analysis. J Dent Res 2016;95:372-9.

  103. Zangrando MS, Damante CA, Sant’Ana AC, Rubo de Rezende ML, Greghi SL, Chambrone L. Long-term evaluation of periodontal parameters and implant outcomes in periodontally compromised patients: A systematic review. J Periodontol 2015;86:201-21.

  104. Gulati M, Govila V, Anand V, Anand B. Implant maintenance: A clinical update. Int Sch Res Notices 2014;2014:908534.

  105. Tarawali K. Maintenance and monitoring of dental implants in general dental practice. Dent Update 2015;42:513-4, 517-8.

  106. Barrak F, Caga D, Crean S. What every dental practitioner should know about how to examine patients with dental implants. Br Dent J 2023;234:309-14.

  107. Lupi SM, Granati M, Butera A, Collesano V, Rodriguez Y Baena R. Air-abrasive debridement with glycine powder versus manual debridement and chlorhexidine administration for the maintenance of peri-implant health status: A six-month randomized clinical trial. Int J Dent Hyg 2017;15:287-94.

  108. Wohlfahrt JC, Aass AM, Koldsland OC. Treatment of peri-implant mucositis with a chitosan brush-a pilot randomized clinical trial. Int J Dent Hyg 2019;17:170-6.

  109. Passarelli PC, Netti A, Lopez MA, Giaquinto EF, De Rosa G, Aureli G, et al. Local/topical antibiotics for peri-implantitis treatment: A systematic review. Antibiotics (Basel) 2021;10:1298.

  110. Thomson-Neal D, Evans GH, Meffert RM. Effects of various prophylactic treatments on titanium, sapphire, and hydroxyapatite-coated implants: An SEM study. Int J Periodontics Restorative Dent 1989;9:300-11.

  111. Hu D, Sreenivasan PK, Zhang YP, De Vizio W. The effects of a zinc citrate dentifrice on bacteria found on oral surfaces. Oral Health Prev Dent 2010;8:47-53.

  112. Mahajani MJ, Kalla M, Sonkesriya S, Mehra P, Laddha R, Akade G. Comparison of the impact of two interdental cleaning devices on the reduction of bleeding around implants. J Pharm Bioallied Sci 2024;16: S192-5.

  113. AlMoharib HS, AlAskar MH, Abuthera EA, Alshalhoub KA, BinRokan FK, AlQahtani NS, et al. Efficacy of three interdental cleaning methods for peri-implant health maintenance of single implant-supported crowns: A randomised clinical trial. Oral Health Prev Dent 2024;22:51-6.

  114. Dumitriu AS, Păunică S, Nicolae XA, Bodnar DC, Albu ŞD, Suciu I, et al. The effectiveness of the association of chlorhexidine with mechanical treatment of peri-implant mucositis. Healthcare (Basel) 2023;11:1918.

SECTION II: PERI-IMPLANT MUCOSITIS

What is the current information regarding the prevalence of peri-implant mucositis?

Several reviews have presented data regarding the prevalence of peri-implant mucositis (PIM) and peri-implantitis and have discussed the diagnosis in detail.[1-4]

PIM was found to occur in approximately 50% of the implant sites and 80% of the patients in a review reporting the prevalence of peri-implant diseases.[1]

In a systematic review and meta-analysispublished in 2017, the mean prevalence of implant-based and subject-based PIM prevalence was 29.48% and 46.83%, respectively, and that of peri-implantitis was found to be 9.25% and 19.83%, respectively.[5] The prevalence of implant-based and subject-based PIM was estimated at 30.7% and 63.4%, respectively, in a meta-analysis published in 2013.[3] Another systematic review and meta-analysis of peri-implant health and disease in 2015 reported that the prevalence of PIM ranged from 19% to 65%, whereas the estimated weighted mean prevalence of PIM was 43%.[4]

Various reviews have reported a prevalence of PIM in function after a minimum of 5 years in the range of 20%–80% of subjects (13%–62% of implants).[1,4,6-21] Short-and medium-term results from two randomized clinical trials[21-25] had PIM after 10 years in three fully edentulous patients with implant-supported maxillary overdentures.[26]

Differences in the definitions of PIM could be one of the reasons for this wide variety of prevalence of mucositis in many studies.[21] Various definitions of PIM (22 articles) were enumerated in a recent publication of the 2017 World Workshops on Classification.[27] Inflammation in the soft tissue, determined by BoP, was common in all definitions, with some definitions also including additional parameters like specific probing depths (PDs),”and/or SUP,” and no bone loss or bone loss ≤2 mm.

One of the studies assessed the degree of severity of PIM.[6] PIM was diagnosed in 48% of patients with BoP, pocket depth of ≥4 mm and bone level <1 thread. The prevalence of patients having per-implant mucositis with greater probing depths of ≥5 mm was 16%, and ≥6 mm was 4%.[4,6]

What do we understand by the term peri-implant mucositis?

The diagnostic definition of PIM as it currently stands is based on case definitions of PIM stated and refined by various authors from 2005 onwards. Following the literature survey post-2017 world workshop, PIM is defined as an inflammatory lesion of the soft tissues surrounding an endosseous implant that is clinically identified by the presence of inflammation, bleeding, and/or SUP on gentle probing, presence or absence of erythema, swelling and without radiographic bone loss.[27-30]

What is the etiopathogenesis of peri-implant mucositis?

The inflammatory process is similar to PIM and gingivitis around natural teeth. After implant placement, salivary glycoproteins adhere to the exposed Ti surfaces, followed by microbial colonization of the area.[31,32] This biofilm formation plays a predominant role in initiating PIM.[33] PIM may be considered a precursor to most of the cases of peri-implantitis (not all cases). However, not all cases of PIM necessarily progress to peri-implantitis.

There is adequate evidence to suggest that peri-implant infections harbor a predominantly Gram-negative bacterial species, as seen with periodontal diseases. However, some reports have suggested the presence of a distinct microflora.[34] The microbial profile of organisms responsible for per-implant mucositis is unclear regarding similarity or variance with periodontal infections.[35]

Immediately after the placement of an implant, an acute inflammatory response is initiated in the area.[36] This foreign body reaction around the implant is a nonspecific immune-driven reaction, with the complement system and macrophages playing a major role in the resulting immune inflammatory balance.[37]

What are the indicators of peri-implant mucositis?

Clinical level

Patients should be continually evaluated for peri-implant mucosal inflammation and the factors that may affect the long-term outcome [Figure 9].[38]

Figure 9.

Figure 9

Open in a new tab

Peri-implant mucosal inflammation

Symptoms

Although a majority of patients suffering from peri-mucositis are symptomless, a few may report with:[39]

  1. History of pain

  2. Discomfort

  3. Bleeding and discomfort with brushing

  4. Swelling, and

  5. SUP occasionally

  6. A relatively common complaint is soreness in the area.[27]

Signs may include

  1. Redness (although the absence of attached gingiva may give a false concept of color change even in healthy mucosa)

  2. Swelling and shininess of soft tissues

  3. BoP combined with visual inflammatory changes and inflammation of the soft tissues around the implant (but not the bleeding induced by injury at the local site)

  4. SUP on the application of gentle pressure at the site.[27]

Redness, swelling, and shininess are important aspects to be observed around the implants to diagnose PIM. Swelling and shininess can be observed after wiping the area with a cotton swab.[38]

Bleeding on probing

Although BoP does not correlate with peri-implant disease, the absence of bleeding does indicate stability. A clear indication is the line of bleeding.[27,40] Isolated dots of bleeding may be a result of traumatic (probing) injury and should not be considered important, particularly in the absence of inflammation.[27]

Suppuration

Light, digital pressure can be applied on the buccal and lingual surfaces of the implants to express SUP.[27] If the SUP is visible with the naked eye, this means that a large number of neutrophils have infiltrated the area, and this condition is suggestive of an advanced disease.[38]

Peri implant probing

According to the Consensus Report of the Sixth European Workshop on Periodontology, “probing is essential for diagnosing peri-implant diseases.” Probing around the implants is done using the walking method, and a light probing force of (0.25N) is applied.[41] The depth of the peri-implant sulcus should generally be < 5.5 mm. A probing depth of 3.5–5.5 mm without inflammation is at an increased risk of breakdown and development of peri-implant disease. The detailed method of probing is described earlier in Section I.

Radiographic assessment

The subsequent radiographs after the baseline intraoral radiographic examination (1 year after functional loading) can be used at future recalls to assess the level of bone at the mesial and distal areas using the fixed reference points.

The bone loss should be no more than >2 mm from the baseline radiograph.[27] Changes of 2 mm or more at any time after the 1st year or later should be considered pathologic.[27] Radiographs are taken to ascertain that there is no progressive bone loss. The detailed method of radiographic assessment is described earlier in Section I.

Is implant sulcus depth a risk factor for peri-implant mucositis?

The risk factors for PIM can be broadly classified into local risk factors, systemic risk factors, and patient-related risk indicators and have been dealt with in detail in Section I. The soft tissue cuff around the implant exhibits less resistance than the adjacent teeth sulcus.[42] In clinical health, the peri-implant mucosa forms a tight seal around the trans-mucosal component of the implant itself, the abutment, or the restoration. The height of the soft tissue around the implant following placement influences the initial probing depth. Generally, the probing depth associated with peri-implant health should be < 3.5 mm. Increasing probing depth up to 5.5 mm without inflammation increases the risk of peri-implant diseases.

Is there a need for a pretreatment investigation?

A patient with a history of systemic diseases should be subjected to suitable investigations to check the status.

What is the treatment of peri-implant mucositis?

The standard of care for PIM usually consists of professional nonsurgical mechanical supra and subgingival debridement of the implant surface along with reinforcing of oral hygiene practices, which results in about 15%–40% reduction in bleeding scores, with an improvement of pocket depth by 0.5–1.0 mm from baseline.[27,30] Professional mechanical plaque control can be performed by ultrasonics with plastic-coated tips, air-polishing devices with glycine powder, Ti curettes, or chitosan brushes.[43] Diode lasers are not recommended with conventional professional mechanical plaque control.[43]

Is there a need for an adjunctive therapy?

  1. The use of adjunctive drug therapies (antiseptic, antibiotic, antimicrobial) or photodynamic therapy (PDT) along with nonsurgical mechanical debridement is not recommended. These adjunctive therapies have reported only a marginal reduction in pocket-depth bleeding propensity when used in conjunction with primary therapy[43-47]

  2. The patients can be recommended to use oral rinse antiseptic mouthwashes, e.g. chlorhexidine, as an adjunct to mechanical plaque control for a limited time.[43]

Is there a need for medication to treat conditions such as diabetes mellitus, cardiovascular disease, or other special conditions?

Medications are not routinely recommended to be used as preoperative antibiotic prophylaxis for diabetic individuals undergoing dental treatments. The use of preoperative antibiotic prophylaxis should be decided on a case-to-case basis for systemically involved patients undergoing dental treatments, considering the patient’s systemic condition and issues related to antibiotic resistance through arbitrary antibiotic usage.[48]

What are the endpoints of the treatment?

The primary and objective endpoint of treatment would include an absence of inflammation, manifested as an absence of bleeding on gentle probing, and the secondary endpoint would be a reduction in pocket depth to 5.5 mm or below.

The clinicians evaluate these endpoints 2–3 months after the intervention, and in the presence of BoP and/or SUP, re-treatment should be initiated.[43] Based on the patient’s oral hygiene, associated risk factors, and the cleanability of the prosthesis, the endpoint evaluation needs to be altered.[43]

Are there any posttreatment adverse effects/complications?

No adverse outcomes have been reported in the literature concerning the treatment of PIM except for overzealous mechanical debridement in thin biotype patients, which may result in gingival recession.[49]

What is the necessity of intervention, and what are the benefits?

PIM may lead to peri-implantitis if left untreated, although it is a reversible condition.[50] So, treating PIM can be considered a preventive step for the onset of peri-implantitis. Inflammation rapidly progresses into peri-implant tissues due to weaker defence mechanisms than periodontal tissues.[12] Lack of periodontal ligament and a reduced number of fibroblasts and blood vessels are responsible for weaker defense.[12] The resolution of PIM may be achievable in most cases and has been demonstrated in many systematic reviews but may not be possible in all patients. Professionally administered plaque removal and reinstitution of oral hygiene practices over 3 weeks have been shown to reverse experimental PIM.[51] Lack of supportive therapy in patients diagnosed with PIM is associated with an increased risk of progression of PIM to peri-implantitis.[52,53]

What are the measures that would ensure the prevention of the recurrence of peri-implant mucositis?

PIM may recur primarily because of the patient not controlling the plaque/biofilm adequately or not following the advised regimens of supportive peri-implant therapy. Re-evaluation of the peri-implant condition (PIC) after treatment of PIM is essential to determine the recall frequency of maintenance therapy. Customizing the maintenance program according to the patient’s needs is recommended.[48] Details of the measures that would prevent the recurrence of PIM by following a PIMC regimen can be found in Section I.

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  44. Ata-Ali J, Ata-Ali F, Galindo-Moreno P. Treatment of periimplant mucositis: A systematic review of randomized controlled trials. Implant Dent 2015;24:13-8.

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  46. Figuero E, Graziani F, Sanz I, Herrera D, Sanz M. Management of peri-implant mucositis and peri-implantitis. Periodontol 2000 2014;66:255-73.

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SECTION III: PERI-IMPLANTITIS AND OTHER PERI-IMPLANT CONDITIONS

Is peri-implantitis truly a disease?

Peri-implantitis (PI) is currently classified as a disease based on its distinct characteristics, progression, and negative impact on oral health. It is characterized by inflammation and infection in the vicinity of dental implants, resulting in bone resorption and potential implant failure if left untreated.[1] The significance of promptly identifying and treating PI cannot be overstated. It is essential to comprehend the pathophysiology and determinants of PI to properly manage and prevent the condition.[2,3] A comprehensive understanding of PI’s molecular mechanisms and etiological factors is essential in developing novel management strategies to prevent further complications and maintain oral health.

Conversely, there are divergent viewpoints about the classification of PI as a pathological condition. Certain researchers contend that the term “disease” may be too strong for the condition, suggesting that it is simply a natural response of the body to the presence of a foreign object, such as a dental implant.[4] It is argued that not all instances of inflammation surrounding implants result in bone loss or implant malfunction and that a certain degree of inflammation may be deemed typical when foreign objects are present in the body.[5] Moreover, they contend that categorizing PI as a “disease” could result in excessive and unwarranted overtreatment, including explanting the implant, even in instances where the inflammation is nonprogressive in nature.[6] The importance of developing a more detailed comprehension of PI is highlighted, considering individual variations in immune response and the potential for resolution of inflammation without aggressive intervention. However, there exists a continuing dispute and differing viewpoints regarding the categorization and therapy of PI.[7] Dental professionals and periodontists must remain informed about the latest research and guidelines on peri-implant diseases to ensure they deliver the best possible evidence-based peri-implant treatment.

Ultimately, whether PI should be categorized as a disease necessitates additional investigation and careful examination of diverse viewpoints within dentistry, implantology, and osteoimmunology.[8] To ensure that patients receive appropriate and evidence-based management, it is crucial to critically review the underlying assumptions and terminology utilized in the classification of PI. Current evidence supports the classification of PI as a disease due to its distinct pathological features, including inflammation, infection, and bone loss around dental implants.[9] Numerous studies have shown that PI is progressive and has the potential to lead to implant failure if left untreated.[10] The presence of microorganisms in the peri-implant biofilm compounds the condition’s infectious dimension, highlighting its disease status.[11] Recent research has additionally identified genetic and immune-related components that contribute to PI susceptibility, emphasizing the disease’s complexity.[12] This evidence underscores the need for tailored and targeted therapeutic approaches for each patient, considering their specific risk factors and immune response. While there may be differing opinions within the field, the accumulating body of evidence supports the classification of PI as a “disease” solely based on the “biofilm-associated etiological dimension.” Recent findings regarding nonbiofilm-related etiologies of PI have prompted researchers to redefine the disorder as being associated not solely with biofilm, but also with other variables that have been insufficiently documented or explored. Thus, at this point in time, it is better and safer to consider and categorize PI as one of the tissue conditions around osseointegrated implants rather a distinct pathology or disease associated with dental implants.

What is the current definition of PI?

PI is a pathological condition that affects the tissues surrounding dental implants, leading to inflammation, bone loss, and potentially implant failure.[13,14,15,16,17] In recent years, the definition of PI has continued to evolve and most recently, in the 2017 World Workshop addressing the classification of periodontal and peri-implant diseases and conditions, a specific criteria to accurately define PI has been provided based on systematic analysis of the published literature.[18] For the last 5 years, this definition has been widely used worldwide, though it has been defined as focused primarily on the biofilm-associated PI disease only.

A simplified, objective, and more practical case definition of PI has been adapted by the expert panel, based on the use of WHO probe for clinical examination of PI, in line with ISP gum care recommendations stated for periodontal disease examination earlier.[19]

Utilizing existing previous records
PI is defined as a presence of peri-implant signs of bleeding and/or suppuration on gentle probing, increased PD compared to previous examinations, and presence of progressive bone loss >2 mm 1 year after the prosthetic load.
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The dynamic nature of case definitions suggests that it continues to evolve as new research emerges and our understanding of the disease deepens. This evolution may involve refinements to existing diagnostic criteria, incorporation of novel diagnostic techniques, and a better understanding of the underlying pathophysiology of PI, improving the existing management strategies and patient outcomes.

What is the prevalence of PI?

In the general population of individuals with dental implants, the reported prevalence of PI ranges from around 1% to 47%, depending on the study and the specific population being investigated.[18] Variations in diagnostic criteria and case definitions of PI across studies also contribute to differences in reported prevalence rates.[18,19,20,21,22,23,24,25,26,27] However, according to a recent systematic review and meta-analysis, the prevalence of PI was determined to be almost 20% at the patient level and 11.5% at the implant level, based on four distinct criteria.[28] The findings show that correctly estimating the genuine prevalence value of PI and achieving higher accuracy in disease categorization depends on the identification of the PI diagnostic criteria. Only the suggested standard definitions and more consistent periodontal measures should be used in future research. Overall, while there is no consensus on the exact prevalence of PI, it is generally considered to be a significant complication associated with dental implants.[28,29]

What are the current concepts in the etiopathogenesis of PI?

The primary cause of peri-implant disorders has been identified as bacterial colonization in biofilm or dental plaque.[10] Since the oral cavity is the same habitat in which teeth and implants reside, it made sense to exhibit a similar microbiota. Nonetheless, several investigations that employed molecular and culture techniques to identify microorganisms have revealed the existence of certain opportunistic bacteria that are unrelated to periodontal disorders.[30,31,32,33] Many analyses and investigations have been carried out to determine whether the microbiota differs from periodontitis; nevertheless, current research indicates that there is not enough evidence to support the differentiating microbiota between periodontal and peri-implant disorders.[10,34,35]

Aseptic bone loss has long been a major concern in orthopedic implants, backed by substantial scientific evidence. The immune system, especially macrophages, can be stimulated by Ti and other metal particles. This can result in the release of pro-inflammatory cytokines and other substances that lead to osteolysis and bone loss surrounding the implant. The significance of particle presence and its effects are highlighted by the variations between the orthopedic and dental contexts, including biomechanical variables, saliva, and bacterial plaque.[36]

Ti particles are implicated in the process by compromising the epithelial barrier, heightening epithelial cell susceptibility to bacteria, and impairing their ability to fend off bacterial attacks.[37,38] Second, both bacteria and Ti particles can independently activate macrophages and prompt cytokine expression, yet their combined action results in a more potent inflammatory response and extensive tissue damage.[39,40] Furthermore, local immunosuppression brought on by the persistent presence of Ti particles and the inflammation they cause may impair macrophage immune responses.[41] In addition, bacteria and inflammatory cells found in peri-implant lesions can promote corrosion and inflammation, which can be made worse by microbial corrosion. Hence, the complex corrosive environment caused by inflammation caused by plaque may be the cause of the existence of Ti particles. Regardless of plaque, they can be the leading cause of the inflammatory response and subsequent loss of bone. On the other hand, they might potentially become apparent as a secondary cause after bacteria-induced bone loss and Ti surface corrosion.

Causally attributing these effects is challenging due to the complex host response to foreign bodies, which involves multiple feedback loops. Tribocorrosion, material degradation, and Ti particle release are promoted by wear, corrosion, and environmental factors.[42] These particles induce inflammation, disrupt cell function, and alter biofilm composition and function, while biofilms themselves contribute to inflammation and further corrosion. Patients reactive to Ti in sensitivity tests had a significantly higher risk of developing PI, releasing elevated cytokine levels upon Ti dioxide contact, which were independently associated with Ti dental implant failure. While there is extensive reporting on the association between biocorrosion, Ti particle presence, and biological implant complications, there is insufficient evidence to establish a unidirectional causal relationship.

According to another diverse school of thought presented by Ihde et al. in 2022, PI is not an “infectious disease” but rather the outcome of the bone’s morphology naturally changing in response to an implant, such as a decrease in the convexity of the bone’s outer surface and a subsequent reduction in the concavity of the inner bone.[43] Although the evidence is frequently inconsistent, traumatized occlusal stress, genetic susceptibility, and excess cement seem to be involved in the beginning and development of peri-implant inflammation.[10]

Clinical relevance

Since the biofilm-associated inflammation of peri-implant tissues has been largely thought of as analogous to the same inflammatory process around natural teeth, hence PI is thought to be a continuum of the pathology from PIM only, akin to the association between gingivitis and periodontitis. However, as there are significant differences in the anatomy of periodontal and peri-implant tissues, such a continuum may not be precisely extrapolated in the real sense in the case of inflammation around implants. Compared to periodontal inflammatory infiltrates, which usually never come into direct contact with the alveolar bone, the peri-implant infiltrate extends to bone tissue, leading to osteitis and eventually activation of the osteoclasts, leading to peri-implant bone loss.[5] Thus, to identify a progression of the pathologic process around implants from the superficial soft tissues to the underlying bone around the implant, only progressive bone loss may be considered the most plausible and precise indicator.

“Progressive bone loss” has been considered the hallmark of PI based on the existing knowledge and published evidence; so, it may not be right, in the strictest sense, to assign a diagnosis of PI in the absence of previous records of the patient without which the progressive nature of the bone loss cannot be established. Moreover, this being the only discriminating feature from PIM, and in the absence of a complete understanding of the factors responsible for the transition of PIM to PI as per evidence available,[44] it is important to detect PI, particularly early cases, a more appropriate definition needs to be identified in cases without previous records. Although a secondary case definition based on clinical and radiographic findings was provided by European federation of Periodontology(EFP) in 2017 for such case scenarios, it provides limited sensitivity for diagnosing PI.[45] Only the identification of moderate-to-severe PI was most precise when utilizing both BoP or SUP (SoP) in conjunction with bone loss of ≥2 mm. These findings emphasize the significance of establishing baseline documentation for accurately diagnosing PI, particularly in its initial stages.

In light of these facts, after extensive literature review and group discussions, the expert panel defined distinct clinical case definitions of peri-implant condition (PIC) for the first time for cases without previous records at the first visit [Figure 10].[46] In the absence of previous records, the case should be assigned a distinct case category based on the pathologic involvement of hard and soft tissue loss as defined below, in an individual case scenario of PIC examination:

Figure 10.

Figure 10

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Distinct clinical case definitions of peri-implant conditions. PIH: Peri-implant health, PIM: Peri-implant mucositis, PIO: Peri-implant osteitis, PI: Peri-implantitis, NPPI: Nonplaque associated peri-implantitis, PIMO: Peri-implant muco-osteitis

  1. Peri-implantitis (PIM): presence of mucosal inflammation and absence of bone loss ≥2 mm 1 year after the prosthetic load

  2. Peri-implant osteitis (PIO): presence of bone loss >2 mm 1 year after the prosthetic load in the absence of mucosal inflammation

  3. A case may be labeled as PIO + PIM when there is the presence of mucosal inflammation and the presence of bone loss >2 mm 1 year after the prosthetic load.

After needful intervention to control mucosal inflammation, i.e. professional mechanical debridement, on a subsequent visit (after 6–8 weeks or 3 months, as applicable), cases may be assigned to one of the categories, including the definitions mentioned above and two new case situations, as given under based on the evident state of soft tissue inflammation and bone loss observed on radiographs, compared to the previous visit:

  • 4

    Peri-implant muco-osteitis (PIMO)/PI: presence of mucosal inflammation and progressive bone loss >2 mm 1 year after the prosthetic load

  • 5

    Nonplaque-associated PI: progressive bone loss >2 mm 1 year after the prosthetic load in the absence of clinical mucosal inflammation.

A step-by-step diagnostic workup/guidance, including the needful management on a case-to-case basis for cases without the previous records at the first visit, has also been provided [Figure 11].

Figure 11.

Figure 11

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Step-by-step diagnostic workup/guidance for cases without the previous records at the first visit. PIH: Peri-implant health, PIM: Peri-implant mucositis, PIO: Peri-implant osteitis, NPPI: Nonplaque associated peri-implantitis, PIMO: Peri-implant muco-osteitis

It is important to acknowledge that the distinction between PIMO/PI and PIO is not merely semantic but has implications for clinical management.[44] The defined terms/labels by the expert panel are aimed at a concise and convenient description of the diverse clinical situations, indicated by distinct names, to enable and appropriate preventive therapeutic management. Thus, the term PI seems justified only for cases indicating concurrent mucosa inflammation and bone tissue around an implant, which is evident by progressive bone loss and may be termed PIMO. This clinical approach highlights progressive bone loss as the salient feature of PI, irrespective of its etiology and status of mucosal inflammation, and indicates PIO as the precursor of PI, emphasizing crestal bone changes as a relevant marker/predictor of potential risk of PI. It is suggested that distinguishing between these PIO and PIMO/PI may allow for more accurate diagnosis and tailored treatment strategies based on the severity of the probable etiology and prevent overdiagnosis and over-treatment of these cases. The consideration of PIMO/PI as a distinct entity apart from “PIO” also underscores the need for a nuanced understanding of the underlying mechanisms contributing to peri-implant inflammation.[47] By recognizing these distinctive variations of peri-implant disease conditions, clinicians can appropriately address the varying degrees of inflammation and bone involvement, thereby facilitating targeted interventions that align with the specific pathological characteristics of each condition. This approach emphasizes the importance of individualized assessment and treatment planning.

What are the risk factors of peri-implant muco-osteitis/PI?

Several risk factors can increase the likelihood of developing PIMO/PI. These risk factors can be broadly categorized into local and systemic factors and have been discussed in detail in Section I. However, some pertinent information regarding risk factors and their assessment, specifically in peri-implant bone loss cases, is provided here.

As marginal bone loss and peri-implant bone loss stem from a complex interplay of various factors, including implant, surgical, prosthetic, microbiological, and host-related elements, it often requires a combination of these factors to surpass an individual patient’s threshold and manifest pathology. Rethinking the paradigm to prevent osteoclast differentiation and activation caused by local or systemic release of proinflammatory cytokines and other molecules, some scholars propose that treatment objectives should target bacterial plaque control and minimize the pro-inflammatory environment surrounding the implant. In addition to the colonization and activity of pathogenic bacteria, other variables identified recently that cause an inflammatory reaction include the presence of Ti particles, wear, corrosion, micromovement of the abutment, occlusal loading, and cement residues. Notably, only a minority (28.8%) of PIMO/PI cases is solely attributable to plaque, while a significant proportion (40.8% and 30.4%) are attributed to surgical and prosthetic factors. In certain instances, multiple risk factors synergize, complicating the identification of the initial trigger.[36]

For a quick, easy, and structured risk assessment of PIMO/PI, an objective risk assessment tool known as IDRA has been devised, similar to as used for periodontal risk assessment.[48] While primarily focused on evaluating individual risk factors, this tool also considers the condition of the implant site. Its purpose is to mitigate the likelihood of peri-implant tissue breakdown. By comprehending the critical factors linked to peri-implant diseases, as documented in the literature, clinicians can selectively address these factors to enhance outcomes in implant therapy. The IDRA is applicable for assessing risk in both edentulous and partially dentate patients, although there may be certain limitations when dealing with edentulous cases. A functional risk assessment diagram is constructed incorporating the following eight parameters based on their documented evidence for an association with peri-implantitis [Figure 12]:

Figure 12.

Figure 12

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A representative diagram from the online tool implant disease risk assessment. IDRA - Implant Disease Risk Assessment; BOP - Bleeding on Probing; PD - Probing Depth; BL - Bone Loss; SPT - Supportive Periodontal Therapy; RM - Restorative Margin; ABC - Representative patient

  1. History of periodontitis

  2. Percentage of sites with BoP

  3. Prevalence of PD ≥5 mm

  4. Bone loss in relation to the patient’s age.

  5. Periodontitis susceptibility as analyzed by the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases

  6. Supportive periodontal therapy

  7. Implant restorative depth

  8. Prosthesis-related factors.

The tool requires validation in diverse clinical settings by multiple retrospective and prospective studies, and the IDRA online tool is available for open access at the following website (http://www.ircohe.net/IDRA).[48]

Can we list some common pointers/alarming symptoms of a potential case of peri-implant muco-osteitis/PI?

The current evidence suggests a rationale for the consecutive assessment of soft-tissue conditions and the extent of bone loss for diagnosing PIMO/PI. Across all the literature reviewed, primarily systematic reviews, varying definitions of PIMO/PI, alongside differing thresholds for the clinical and radiographic parameters, were documented.[49,50,51,52,53,54] Based on that, these common pointers and alarming symptoms that may indicate the presence of potential PIMO/PI:

  1. Bleeding on probing: Bleeding from the peri-implant tissues on probing can be an early sign of inflammation and may indicate the presence of PIM or PIMO/PI

  2. Increased probing depth: An increase in probing depth around the implant compared to previous measurements or baseline values may suggest peri-implant tissue inflammation and possible bone loss [Figure 13]

  3. SUP: Pus discharge or SUP from the peri-implant sulcus or pocket is a sign of active infection and inflammation, indicating advanced PIMO/PI

  4. Swelling and redness: localized swelling, erythema (redness), and tenderness of the peri-implant tissues may indicate an inflammatory response and the presence of PIMO/PI

  5. Loosening of implant or prosthesis: Mobility or loosening of the implant or implant-supported prosthesis may suggest bone loss and peri-implant tissue destruction, especially in advanced cases of peri-implant loss

  6. Changes in soft-tissue contour: Alterations in the contour and appearance of the peri-implant soft tissues, such as recession or loss of papilla height, may indicate underlying peri-implant tissue inflammation and bone loss

  7. Radiographic evidence of bone loss: Radiographic evaluation, such as periapical or panoramic radiographs, may reveal peri-implant bone loss, characterized by a decrease in bone density or the presence of radiolucent areas around the implant compared to baseline radiographs

  8. Pain or discomfort: Persistent pain or discomfort in the region of the implant, especially upon biting or chewing, may indicate peri-implant inflammation and tissue damage

  9. Halitosis (bad breath): Foul breath odor may be associated with peri-implant infection and inflammation, especially if accompanied by other signs and symptoms of PIMO/PI

  10. Gingival recession: Recession of the peri-implant soft tissues, leading to exposure of the implant surface, may occur because of PIMO/PI-related bone loss and soft-tissue destruction

  11. Failure of previous implant treatments: Previous implant failures or complications, such as implant mobility or peri-implant infections, may indicate a predisposition to PI and the need for careful monitoring and management

  12. History of periodontal disease or risk factors: Patients with a history of periodontal disease, poor oral hygiene, smoking, diabetes, or other systemic conditions associated with increased risk for PIMO/PI should be closely monitored for signs and symptoms of peri-implant complications.

Figure 13.

Figure 13

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A case of Peri-implantitis with (a) Clinical and (b) Radiographic features

What are the modalities and the endpoints for the nonsurgical treatment management of peri-implant muco-osteitis/PI?

Nonsurgical treatment modalities for managing PI aim to control infection, reduce inflammation, and promote peri-implant tissue health without requiring invasive surgical intervention. These nonsurgical approaches are typically employed as the initial treatment step or in conjunction with surgical therapies for comprehensive management of PIMO/PI.[52,55,56,57]

Professional mechanical debridement

  1. Scaling and root planing around the implant: Removal of bacterial biofilm and calculus deposits from the implant surface and adjacent soft tissues using hand instruments, ultrasonic scalers, or mechanical instruments (refer to Section I for details regarding instrumentation)

  2. Air polishing: Use of abrasive particles propelled by compressed air to remove biofilm and stains from implant surfaces and peri-implant tissues.

Local antimicrobial therapy

  1. Topical antiseptic solutions: Application of antimicrobial agents such as chlorhexidine or povidone-iodine to the peri-implant tissues to reduce bacterial load and inflammation

  2. Local antibiotic therapy: Placement of antibiotics such as minocycline or tetracycline directly into peri-implant pockets or defects to target specific pathogens and suppress bacterial growth.

Adjunctive therapies

  1. Laser therapy: Utilization of lasers, such as diode lasers or erbium lasers, to decontaminate implant surfaces, reduce bacterial load, and promote tissue healing through photobiomodulation

  2. Photodynamic therapy: Application of photosensitizing agents followed by exposure to light of specific wavelengths to generate reactive oxygen species and selectively target and destroy bacteria in peri-implant tissues.

Oral hygiene reinforcement and patient education

  1. Instruction on proper oral hygiene practices: Provide guidance to patients on effective brushing techniques, interdental cleaning methods (e.g., flossing, interdental brushes), and the use of antimicrobial mouth rinses

  2. Reinforcement of regular maintenance visits: Emphasize the importance of attending scheduled maintenance appointments for professional cleanings and monitoring of peri-implant health.

Systemic antibiotic therapy

In widespread or systemic infection cases, systemic antibiotic therapy may be prescribed to complement local antimicrobial treatments and control bacterial growth.

Anti-inflammatory medications

Nonsteroidal anti-inflammatory drugs or corticosteroids may be prescribed to reduce inflammation and alleviate symptoms associated with PIMO/PI.

Oxygen/ozone therapy

Oxygen/ozone therapy involves the use of ozone gas or ozonated water to disinfect and promote the healing of peri-implant tissues by enhancing oxygenation and modulating the local immune response.

Nonsurgical therapy for PI is prioritized over surgical intervention. It has been proposed that reducing bacterial load is essential for enhancing treatment success and creating a favorable environment for potential surgical procedures.[58] Air-abrasion systems and Er: YAG laser treatments have demonstrated a superior reduction in BoP compared to mechanical debridement with chlorhexidine in the short term (<12 months). However, they do not show a significant reduction in pocket depth.[59] Ti curettes are also effective for nonsurgical therapy. The addition of antiseptics, antibiotics, or probiotics has not proven to be useful in reducing BoP and PD in the short term.[59] Various instrumentation and materials tested have shown similar effects on soft-tissue levels in both test and control groups. Laser therapies such as Er, Cr: YAG, Er: YAG, and Nd: YAG have demonstrated short-term effectiveness (<6 months) in reducing BoP compared to mechanical debridement.[60] The effectiveness of nonsurgical treatment of PI, typically involving only mechanical debridement, includes:[18,58]

  1. A reduction in BoP extent (20%–50%) from baseline

  2. Improvement in pocket depth (reduction of approximately 1 mm) from baseline.

However, despite these efforts, more than 50% of patients treated nonsurgically may still experience persistent disease, such as ongoing BoP, increased pocket depth, and radiographic bone loss, necessitating surgical intervention.[52,61,62,63]

Endpoint evaluation

The panel suggests monitoring residual inflammation/BoP/SUP and probing depths to evaluate the effectiveness of the nonsurgical phase of PI treatment. In addition, patient satisfaction, maintenance of good oral hygiene, and the cleanliness of the prosthesis should be considered.[55]

We recommend using the following criteria at the implant level as therapy endpoints: Residual probing depths ≤ 5.5 mm with no BoP and/or SUP and absence of progressive bone loss.

It is recommended that the outcomes of the nonsurgical phase of therapy be reassessed after 6–12 weeks, with frequent monitoring during the healing process being prudent (Table 2, for recall interval).[55]

Do adjunctive therapies such as implant surface decontamination, antimicrobials (local and systemic), therapeutic procedures such as lasers, photodynamic therapy, and probiotics provide an additional benefit in the management of PI?

Adjunctive therapies such as implant surface decontamination, antimicrobials (local and systemic), therapeutic procedures such as lasers, PDT, and probiotics may provide additional benefits in the management of PI. These modalities may complement traditional nonsurgical and surgical treatments by targeting microbial biofilms, reducing inflammation, and promoting tissue healing. While these adjunctive therapies show promise in the management of PI, their effectiveness may vary depending on factors such as treatment protocol, patient compliance, and individual patient characteristics, and they are not conclusively supported by published literature.[55] Contemporary evidence suggests limited effectiveness of two of these approaches, namely Lasers and PDT.[64] Laser treatment may improve bone gain in PI defects, reduce BoP and PDs, and be comparable to mechanical therapy. However, contemporary literature fails to provide definitive conclusions based on statistically significant differences observed between the approaches.[65] PDT may also enhance the benefits of mechanical implant treatment methods, yet the selection of photosensitizer in antibacterial PDT also affects the periodontal recovery effect of treatment.[66,67] Therefore, any such adjunctive therapies should be tailored to each patient’s specific needs and incorporated into a comprehensive treatment plan in conjunction with conventional therapies for optimal outcomes in managing PI based on the clinician’s preference.

What are the modalities and the endpoints for the surgical management of PI?

Surgical therapy for the management of PIMO/PI may be indicated when nonsurgical interventions fail to adequately control infection, resolve inflammation, or halt disease progression. Further, these procedures aim to access and debride infected peri-implant tissues, remove granulation tissue, and promote regeneration of supporting bone and soft tissues.[55,56,57,61,62] The specific type of surgical therapy selected depends on factors such as the extent of peri-implant tissue damage, the severity of bone loss, and anatomical considerations.[68,69] Here, are the indications and types of surgical therapy for the management of PIMO/PI.

Open flap debridement

  1. Indication: Used to access peri-implant defects and thoroughly debridement of infected tissues

  2. Procedure: Incision and elevation of a flap to expose the peri-implant defect, followed by removal of granulation tissue, thorough debridement of implant surfaces, and irrigation with antiseptic solutions

  3. Benefits: Allows direct visualization and access to peri-implant defects, facilitates debridement of infected tissues, and promotes the regeneration of supporting tissues.

Guided bone regeneration

  1. Indication: Used for defects with significant bone loss to promote bone regeneration and fill osseous defects

  2. Procedure: Placement of barrier membranes (e.g. resorbable or non-resorbable membranes) to exclude epithelial ingrowth and provide space for bone regeneration, followed by bone grafting or bone substitutes to stimulate bone formation

  3. Benefits: Helps regenerate peri-implant bone and restore osseous support around the implant, improving long-term stability and function.

Resective osseous surgery

  1. Indication: Used for defects with irregular bone contours or excess bone formation (e.g., overgrowth), requiring reshaping or recontouring of the bone to facilitate implant hygiene and maintenance

  2. Procedure: Surgical resection or osteoplasty to remove excess bone and create a smooth, accessible contour around the implant

  3. Benefits: Enhances implant hygiene and accessibility for plaque control, reduces the risk of plaque accumulation and recurrent peri-implantitis, and improves long-term implant prognosis.

Soft tissue augmentation or grafting

  • Indication: Used for defects with soft-tissue deficiencies or mucosal recession, requiring augmentation to improve soft tissue contours and esthetics

  • Procedure: Soft tissue grafting or augmentation techniques (e.g. connective tissue grafts, free gingival grafts, or pedicle flaps) to increase keratinized tissue width, enhance soft tissue thickness, and improve peri-implant mucosal architecture

  • Benefits: Improves peri-implant soft-tissue health, stability, and esthetics and may help prevent future mucosal recession or soft-tissue complications.

Implant surface decontamination

  1. Indication: Used to remove microbial biofilms and contaminants from implant surfaces to promote re-osseointegration and prevent disease recurrence

  2. Procedure: Mechanical or chemical decontamination of implant surfaces using techniques such as air-abrasive methods, laser therapy, or chemical irrigation with antiseptic solutions

  3. Benefits: Reduces bacterial load on implant surfaces, enhances tissue healing, and promotes successful osseointegration following surgical therapy.

Endpoint evaluation

The endpoints of surgical treatment for PI should be evaluated based on clinical, radiographic, and patient-centered parameters to assess treatment success, monitor healing progress, and ensure the long-term stability and function of dental implants.[55,70,71,72]

• It is advised for clinicians to assess disease resolution at the implant level by observing absence of BoP, absence of SoP, pocket depth (PD) ≤5.5 mm, and absence of progressive bone loss in comparison to pretreatment bone levels.

Clinical parameters should be documented 6 months after treatment, and radiographs should be taken at 12 months (Table 2, for recall interval).

In the long-term assessment of treatment outcomes, it is suggested to consider complication-free survival of the implant and implant-supported prosthesis, along with factors such as patient satisfaction, including aesthetic appreciation.

Is there a need to involve specialists in PI patient care?

In many cases, involving specialists in PI patient care can be beneficial, especially when dealing with complex or advanced cases. While general dentists may manage uncomplicated cases of PI, specialized training can offer additional expertise and resources for more comprehensive evaluation and treatment.[19] Understanding bone grafting techniques and soft-tissue management is crucial, especially in cases where there is insufficient bone volume or soft-tissue support for implant placement. Proficiency in interpreting advanced imaging modalities such as CBCT scans and training in recognizing and managing complications related to implant surgery and restoration is critical for accurate treatment planning and assessment in these patients. Keeping up-to-date with advancements in implant dentistry through continuing education courses, seminars, and workshops is essential for improving skills and staying abreast of new techniques and technologies.[55] With additional training in these areas, general dentists can enhance their expertise in implant rehabilitation and provide high-quality care to their patients.

Active participation of a skilled general dentist/periodontist in implant maintenance protocols is required for the long-term prevention, diagnosis, and treatment of peri-implantitis.[19,55] Collaboration with other dental specialists, such as periodontists and prosthodontists, may be necessary for comprehensive implant rehabilitation cases.

Financial support and sponsorship

The project was supported by an unrestricted educational grant from Colgate Palmolive (India).

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

Authors extend thankfulness for graciously contributing clinical photographs and illustrations for use in this manuscript to Lt Col (Dr.) Rahul Rai [Figure 3] Lt Col (Dr.) Navin Kaul [Figure 9], Maj (Dr.) Manek Sharma [Figure 13] and Dr. Sunil Mishra (Colgate-Palmolive, India).

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