Peri-implantitis: Infection Around Implants and Modern Treatment Methods

Peri-Implantitis Is Inflammation That Has Reached the Bone

Peri-implantitis is a progressive inflammatory disease of the tissues around a dental implant. It starts in the gum around the implant and, when it is not treated, spreads into the bone that holds the implant in place. The result is gradual bone loss around the implant, which in advanced cases can loosen it and lead to its removal.

The disease does not appear suddenly. It is preceded by an earlier stage called peri-implant mucositis, in which the inflammation is confined to the soft tissue. Mucositis shows as redness, swelling and bleeding when the gum around the implant is probed or brushed, and at that stage no bone has been lost. The dividing line between the two conditions is the bone. Mucositis can be resolved with professional cleaning and better daily hygiene, and the tissue can return to health. Peri-implantitis has already destroyed some of the supporting bone, and that bone does not grow back on its own; treatment can stop the disease from progressing and, in suitable defects, rebuild part of what was lost.

This is why the timing of diagnosis matters so much. The same bacterial plaque drives both stages, and the step from mucositis to peri-implantitis can happen without pain. A patient who notices bleeding around an implant and has it checked is usually dealing with the reversible stage. A patient who waits until the implant feels loose is usually dealing with significant bone loss. Regular examinations with probing and, where needed, X-rays are the way the two stages are told apart.

How Common Peri-Implant Disease Is

Peri-implant disease is common. An AO/AAP systematic review that included 102 studies with 13,030 patients reported a patient-level prevalence of 46% for peri-implant mucositis and 21% for peri-implantitis (PubMed 40489307). Put simply, about one implant patient in five has peri-implantitis at a given time, and close to half have mucositis.

The risk also accumulates with the years an implant is in use. In the same review, the weighted mean incidence at the patient level within 20 years of function was 53% for mucositis and 22% for peri-implantitis (PubMed 40489307). The authors concluded that more than half of the patients treated with dental implants were affected by peri-implant diseases over a 10-year follow-up period, with mucositis the most frequent condition (PubMed 40489307).

These figures change how a healthy check-up should be read. An implant that is healthy one year can develop inflammation later, so a single good result does not settle the question for the life of the implant. Regular follow-up exists to catch the change early.

It is also worth keeping the numbers in proportion. Most implants in these studies were not lost, and mucositis, the most common finding, is the stage that responds to cleaning. The figures are a reason for regular maintenance, and they do not mean that implants are an unreliable treatment. They also explain why the care of an implant continues after the final crown has been fitted.

Causes and Risk Indicators

The main cause of peri-implantitis is bacterial plaque that collects around the implant and the crown at the gum line. When that plaque is not removed, the gum around the implant becomes inflamed, and over time the inflammation can move deeper. For this reason, many cases are preventable with a consistent hygiene routine and regular professional cleaning.

The AO/AAP review looked at which patient factors went together with the disease. For peri-implantitis, the significant risk indicators were periodontitis, diabetes mellitus, smoking and alcohol consumption; for mucositis they were periodontitis, obesity and smoking (PubMed 40489307). The authors stressed that only risk indicators could be identified in the available evidence, which means these factors are associated with the disease without being proven single causes (PubMed 40489307). Periodontitis and smoking appeared for both conditions.

A history of gum disease deserves particular attention. The bacteria that caused bone loss around natural teeth can do the same around implants, so patients who lost teeth to periodontitis are usually advised to have that disease under control before implants are placed and to keep to a close maintenance schedule afterwards.

Other factors are discussed in clinical practice as contributors. Heavy grinding or an overloaded restoration can strain the bone around an implant. Excess cement left under a crown can irritate the gum. Treatments such as chemotherapy and radiotherapy, and some medications that affect bone healing, can reduce the tissue's ability to respond. Each of these is assessed as part of the implant plan and at follow-up visits.

Early Signs Around an Implant

The early signs of peri-implant disease are mild, which is why they are easy to overlook.

Bleeding and swelling of the gum around the implant are usually the first signs. The bleeding can appear while brushing, while cleaning between the teeth or on its own, and the gum may look redder or puffier than the gum around neighbouring teeth. At this stage the problem is often still mucositis, and it is the right moment to book an examination.

Bad breath or a bad, sometimes metallic, taste can follow when bacteria are trapped between the gum and the implant surface. Pus is a later sign. It means the body is trying to contain an established infection, and it can be seen as a small discharge when the gum is pressed. The gum may also begin to recede, exposing part of the implant or the metal abutment.

Movement of the implant is a late and serious sign. An implant that has fused with the bone does not move, so any mobility suggests that much of the supporting bone has been lost.

A patient with one of the risk indicators above, such as a history of periodontitis, diabetes or smoking, has more reason to report these signs early. In the clinic, the examination includes measuring the depth of the pocket around the implant, checking for bleeding and pus, and comparing current X-rays with those taken when the crown was fitted, so that any change in bone level can be measured.

Daily Care That Protects Implants

Implant treatment continues after the final crown is fitted. The implant has no natural tooth root around it, and the seal between the gum and the implant is more vulnerable to plaque, so daily cleaning carries a large share of the prevention.

Brushing at least twice a day with a fluoride toothpaste is the base of the routine. A soft implant toothbrush is recommended for the area around the implant, and medium or hard bristles are avoided because they can damage the gum. Cleaning between the teeth is the second part. Floss, interdental brushes with a coated wire and water flossers can all be used, and water flossers make it easier to reach areas around implant bridges and full-arch restorations. Metallic interdental brushes and other hard or abrasive tools are avoided on the implant surface because they can scratch it, and a scratched surface holds plaque more easily.

Antiseptic mouthwashes can be added for a limited period when the dentist recommends them, for example after surgery or during treatment of inflammation. An alcohol-free rinse is usually chosen. A mouthwash supports brushing and interdental cleaning, and it does not replace the mechanical removal of plaque.

Nutrition and habits play a supporting role. A diet low in frequent sugary and acidic snacks is better for the whole mouth, and very hard foods such as bones and hard nuts can overload a crown. Foods rich in vitamins C and D, calcium and protein support the gum and bone. Stopping smoking is a valuable change for a patient who smokes, given that smoking is a risk indicator for both stages of the disease.

Non-Surgical Treatment and Adjunctive Measures

Treatment depends on the stage of the disease. Early stages are simpler to manage, and advanced stages can require surgery or, in the most severe cases, removal of the implant.

The European Federation of Periodontology has published an S3-level clinical practice guideline for peri-implant diseases, built on 13 commissioned systematic reviews (PubMed 37271498). The guideline treats care as a sequence: prevention starts when implants are planned, placed and loaded; once they are in function, a supportive peri-implant care programme with periodical assessment of the tissues follows; and mucositis or peri-implantitis found at those visits is treated (PubMed 37271498).

The first step of treatment is removing the plaque and hardened deposits from the implant and the crown. This is done with instruments designed for implant surfaces, so the surface is cleaned without being damaged. Oral hygiene instructions and, where needed, changes to the crown to make it easier to clean are part of the same step. For mucositis, this is often enough. Laser-assisted cleaning is one of the methods used to decontaminate the surface.

Additions to non-surgical cleaning have been studied. A systematic review of controlled clinical trials with at least 6 months of follow-up included 9 investigations of local antimicrobials, systemic antimicrobials and probiotics (PubMed 37143407). Systemic antimicrobials gave significantly greater reductions in probing depth and bleeding on probing, especially at initially deep sites of 6 mm or more, while local antimicrobials led to modest improvements in probing depth (PubMed 37143407). The studies differed too much to be combined in a meta-analysis, so the choice of an additional measure is made for the individual case (PubMed 37143407).

Surgical Treatment When Bone Has Been Lost

When the pockets around the implant stay deep after non-surgical treatment, or when X-rays show a clear bone defect, surgery is considered. The aim of surgery is to reach the implant surface directly, clean it thoroughly and, where the shape of the defect allows, rebuild part of the lost bone.

One surgical approach is open flap debridement: the gum is lifted, the implant surface is decontaminated and the gum is closed again. Reconstructive surgery goes further and fills the bone defect with a graft material, sometimes covered with a membrane, so that new bone can form. Flap procedures can also be used to reposition the gum and protect the implant surface. Some patients need a combination of these approaches.

The evidence on reconstruction comes from an AAP/AO systematic review and network meta-analysis. Across 18 randomised trials with 635 patients and 687 implants, reconstructive surgery reduced probing depth, limited mucosal recession and gained radiographic bone level compared with open flap debridement alone (PubMed 40476895). It gave no additional benefit for bleeding on probing or suppuration, and smoking and the starting measurements of the defect also affected the results (PubMed 40476895). Reconstruction therefore helps with the shape of the bone and the gum, while control of the inflammation still depends on cleaning and maintenance.

In severe cases, where most of the supporting bone is gone or the implant is mobile, the surgeon may recommend removing the implant. The site is then allowed to heal, bone can be grafted, and a new implant can be planned after recovery. The exact treatment is decided after the examination and X-rays, according to the stage of the disease and the shape of the defect.

Recovery and Follow-Up After Treatment

Treatment for peri-implantitis is carried out under local anaesthesia, so pain during the procedure is minimal. Mild discomfort, swelling and sensitivity afterwards are usual and generally settle within a few days. Recovery time depends on the extent of the treatment: non-surgical cleaning usually needs a couple of days, while flap or grafting surgery needs one to two weeks for initial healing and several months for the bone to mature.

After treatment, follow-up is the part that keeps the result. Professional cleaning and monitoring every three to six months is the usual interval, and the interval is set according to the patient's risk. At these visits the dentist checks for bleeding, measures the pockets around the implant and, at intervals, compares X-rays with earlier ones. Because the disease can return, early detection at a routine visit is the aim.

Lifestyle factors affect healing as well. Smoking slows healing and is a risk indicator for both mucositis and peri-implantitis, so stopping is advised. Chronic conditions such as diabetes are kept under control with the patient's physician, and any gum disease around the natural teeth is treated at the same time as the implant.

Patients who have their implants placed in Istanbul and return home can continue this maintenance with their local dentist, bringing the treatment records and X-rays so that bone levels can be compared over time. Peri-implantitis is preventable in many cases and treatable when it is found, and a steady routine of home care and check-ups protects the implant over the long term.

Author: DDS, PhD Ömer Faruk Şarkbay (Implantology Specialist)