What peri-implantitis is
Peri-implantitis is an inflammatory disease of the tissue around a dental implant. It affects the gum and the bone in which the implant is anchored. The cause is bacteria that settle on the implant surface and in the sulcus, the gap between implant and mucosa.
Important is the distinction from peri-implant mucositis, the preliminary stage. Mucositis is a pure mucosal inflammation without bone loss, comparable to gum inflammation at the natural tooth. It is reversible if the bacteria are removed in time. Peri-implantitis, on the other hand, is mucositis with progressive bone loss and without therapy is not self-limiting.
Studies on frequency differ depending on definition and observation period. After ten years the peri-implantitis prevalence is between ten and twenty percent of all implants, depending on the source. It is thus the most common cause of late implant loss and in most cases preventable with good aftercare.
How peri-implantitis develops
The mechanism is essentially the same as with periodontitis at the natural tooth: bacterial plaque accumulates on the implant surface, the immune system reacts with inflammation, in the course bone is broken down, the implant loses its anchoring.
What makes peri-implantitis special is the implant surface itself. Modern implants have a rough surface that promotes bone healing. This roughness, however, also offers bacteria a larger attack surface as soon as the mucosa around the implant recedes. Once bacteria have colonized the rough surface, mechanical cleaning is more difficult than on a natural tooth.
Risk factors
Not every implant carrier develops peri-implantitis. Studies identify several risk factors that significantly increase risk:
- Pre-existing periodontitis. Patients with periodontitis at natural teeth, current or past, have a two to four times elevated peri-implantitis risk.
- Smoking. Increases risk by factor of two to three. Reduces wound healing and immune defense in the oral area.
- Inadequate oral hygiene. Plaque is the prerequisite for inflammation. No plaque, no peri-implantitis.
- Uncontrolled diabetes mellitus. Weakens immune defense and wound healing.
- Insufficient recall intervals. Without regular professional cleaning the plaque is never fully removed.
- Constructive problems. Poorly fitting suprastructures, hard-to-clean transitions or implants placed too close together impede hygiene.
Symptoms and early detection
Peri-implantitis is insidious because it rarely causes pain in the early stages. In contrast to acute infection at the tooth, the typical throbbing pain is missing. The most common signs are:
- Bleeding on probing or brushing in the implant area
- Redness and swelling of the mucosa
- Deepened probing depths (pocket formation)
- Pus discharge from the sulcus with active infection
- Bone loss on X-ray compared to the initial situation
- Visible implant body when the mucosa has receded
- Implant loosening, however only in very advanced cases
Pain typically only occurs when the inflammation is far advanced or an acute infection with pus formation exists. By then considerable bone loss has often already occurred.
Early detection therefore runs through regular check-ups, not through one’s own pain impression. At every recall session the probing depths at the implant should be documented and compared with the preliminary examination.
Diagnosis
Diagnosis is clinical and radiological. The clinical examination includes probing with a special plastic probe (metal probes would damage the implant surface), assessment of bleeding on probing and search for pus or swelling.
On X-ray the bone loss shows as loss of the bony border around the implant. With a healthy implant the bone reaches near the implant shoulder. With peri-implantitis the bony border is more deeply broken down, often with crater-shaped defect around the implant body.
With suspicion of peri-implantitis and unclear findings, a 3D image (CBCT) can provide clarity about the extent of bone loss.
Treatment
Therapy depends on the stage. There are established protocols, the study evidence for the most effective procedures is still developing.
Mucositis (preliminary stage)
With pure mucosal inflammation without bone loss, professional cleaning of the implant and suprastructure is usually sufficient. The treatment is supplemented with instructions for home care and a close check after three to six months. In most cases the mucositis heals completely if the plaque is consistently removed.
Peri-implantitis (bone loss)
With proven bone loss a distinction is made between non-surgical and surgical therapy:
Non-surgical. Mechanical cleaning with powder jet (glycine or erythritol powder), plastic or titanium curettes and possibly laser decontamination. Supplemented with antibacterial rinses with chlorhexidine or locally applied antibiotics. This therapy is successful with moderate peri-implantitis, especially if the risk factors (smoking, plaque) are addressed at the same time.
Surgical. With advanced bone loss the gum is surgically lifted, the implant surface is cleaned under direct view and bone augmentation material is possibly placed in the defect. The study evidence for regeneration is limited, with moderate success rates.
Explantation. With very advanced bone loss, missing therapy success or implant loosening, removal of the implant is the only option. After healing a new implant can be placed, often with preceding bone augmentation.
Treatment of peri-implantitis is more elaborate and less predictable than prevention. That is why regular recall hygiene with implant patients is so important.
Prevention. What really works
The most effective measures to avoid peri-implantitis are not spectacular. They are consistent and well-documented:
Home care
Daily thorough brushing with a soft toothbrush, at least two minutes morning and evening. Interdental care with interdental brushes or superfloss at the implant. Electric toothbrushes are more effective than manual toothbrushes at plaque removal.
Mouth rinses with chlorhexidine are an option for phases of increased inflammation tendency but are not suitable for continuous use (tooth discoloration, taste change).
Professional recall hygiene
The most important preventive measure. We recommend implant patients:
- With stable conditions: two dental hygiene sessions per year plus one annual dental check.
- With pre-existing periodontitis or elevated risk: three to four sessions per year.
- With acute mucositis: therapy session plus check after three to six months.
At the recall session the implant surface is cleaned with powder jet and plastic curettes. Metal instruments are avoided because they can damage the implant surface. Probing depths are documented and compared with the previous session.
Reduce risk factors
Smokers have a significantly elevated peri-implantitis risk. A reduction or stop pays off even after implant placement. Well-controlled diabetes also significantly reduces risk. With pre-existing periodontitis the recall intervals should be shorter.
Constructive hygiene ability
When planning the implant and suprastructure we pay attention to hygiene ability: sufficient distance between multiple implants, well-accessible transitions, crown margins that do not lie too deep. A hard-to-clean construction is a risk factor that cannot easily be corrected later.
What Resident does with implant patients
Implant patients receive a structured recall program with us. After incorporation of the crown the recall appointments are planned, usually first every three months for the first year, then in semi-annual or annual intervals depending on individual risk profile.
At every recall session we document the probing depths and the plaque values at the implant. With changes (increasing depth, bleeding, visible bone loss on X-ray) we react early with therapeutic cleaning and tighter check.
Complex peri-implantitis cases with extensive bone loss are treated at our Bellevue location by Dr. Dejan Dragisic, oral surgery specialist. Aftercare returns to your home location. More on this on the implant spoke Bellevue.
If you have an implant and are unsure when your next hygiene is due, arrange an appointment at your Resident practice. We check your implant status and set an individual recall plan.