Peri-implantitis, peri-implant mucositis, and peri-implant gingivitis

What is peri-implantitis?

Peri-implantitis is not dissimilar to periodontal disease in that it has 2 phases; peri-implantitis which is similar to periodontitis and peri-implant mucositis which is similar to gingivitis.  The difference between peri-implant mucositis and peri-implant gingivitis is the later has keratinized gingiva.  Peri-implantitis is defined as infection with suppuration (pus) with progressing bone loss after the adaptive phase, in other words after the implant has healed into the bone.  It starts with peri-implant mucositis, an inflammatory process of the soft and hard tissues surrounding an implant but no progressing bone loss. Peri-implantitis and mucositis are associated with loss of supporting bone, bleeding on probing/flossing, redness, and suppuration.
Table with classifications of peri-implantitis

Causes of  peri-implantitis is complex and related to a variety of factors:

  1. Patient-related factors including systemic diseases (e.g. diabetes, osteoporosis), dry mouth, and prior dental history (periodontitis)
  2. Social factors such as inadequate oral hygiene, smoking, and drug abuse
  3. Parafunctional habits (bruxism and malocclusion) and occlusal over-load.
  4. Excess cement and loose, over-contoured, or poor fitting crowns.  Incomplete crown or abutment seating.
  5. Lack of keratinized tissue (especially less than 2mm)
  6. Poorly positioned implants

Risk factors for peri-implantitis are similar to the causes but there is a nice risk assessment survey on FOR

Risk assessment for peri-implantitis on FOR and from playing around with it a little the biggest impacts are previous periodontal disease and and plaque.

Treatment of peri-implantitis

Although implants have demonstrated a very high survival rate, a recent systemic review shows one-fourth of patients and one-fifth of implants will develop peri-implantitis after 5-10 years.  Many methods of treating peri-implantitis have been documented in the literature and most focus on removal of the contaminating agent from the implant surface. These treatments include:
  1. Mechanical debridement with or without systemic antibiotic treatment
  2. Debridement with or without localized drug delivery and chlorhexidine oral rinses
  3. Mechanical debridement combined and CO2, LASER decontamination, or LAPIP protocol
  4. Surgical debridement with or without guided bone regeneration (GBR) for reparation of bony and soft-tissue defects.

To date, studies suggest that nonsurgical treatment of peri-implantitis is unpredictable, and the use of chemical agents such as chlorhexidine has only limited effects on clinical and microbiological parameters. Adjunctive local or systemic antibiotics have shown to reduce bleeding on probing and probing depths in combination with mechanical debridement. Beneficial effects of laser therapy on peri-implantitis have also been shown. Left untreated chronic peri-imlpantitis results in epithelial down-growth, bone resorption, soft tissue encapsulation and a hopeless implant.

My treatment protocol for peri-implantitis

  1. Double check bite to ensure tooth is not taking excessive biting force (malocclusion).
  2. Cemented crowns – access screw and removal; if find cement removal piezo if not add #3
  3. Piezo debridement, EDTA and citric acid then CHX then sterile saline rinse, localized dual drug delivery with Arestin antibiotic, and prescription for chlorhexidine rinse for 10 days. Only do this an an adjunct or pre-treatment to step 4.
  4. Open flap surgery, piezo debridement, air powder abrasive?*** (has tons of great studies), EDTA and citric acid treatment with Ti brush, CHX, saline flush, CO2 (or Er:YAG) laser treatment with guided bone regeneration.** (hydrogen peroxide irrigation daily, then saline, then minocycline for 3 days) or
  5. In complete vertical loss areas flap and smooth exposed threads, protocol below.*
This example appears to use diode laser?  Believe better to use CO2 or Er:YAG.

Unknown what laser best CO2, Er:YAG, and maybe diode can decontaminate as well as sandblast. Natto JOMI 2015

If you have any questions about wheaton implant care or service please feel free to email me or contact my office.  If you live in the Wheaton/Glen Ellyn area we would be happy to see you for a complimentary evaluation to see if you are an implant candidate.

How smooth dental implant threads

*Smooth threads by

  1. Course diamond
  2. 12 flute
  3. 30 flute
  4. brown point
  5. green point
  6. advance flap 1-2mm
** Ab protocol and flap, piezo, Er:Cr:YSGG 6W 30% H2O/30% air or scrub EDTA or citric acid, CHX, saline, bone, PRP membrane, suture Petrungaro
*** Sodium bicarbonate (baking soda) Profi II Ceramic at 70lb for 1 minute 10mm away Vieira ID ID 12 Perioflow with glycine doesn’t leave anything behind. Fine bicarbonate powder for 60 seconds using Prophy-Jet, Dentsply with a contra-angled tip to reach all areas of the exposed implant followed by 60-second irrigation sterile saline delivered by Infinity Irrigator, Ace Surgical. Froum 2012

Peri-implantitis research articles of interest

Cochrane = no answers yet
Grunder U et al. Treatment of ligature-induced peri-implantitis using guided tissue regeneration: a clinical and histologic study in the beagle dog. Int J Oral Maxillofac Implants 1993;
Klinge B et al. A systematic review of the effect of anti-infective therapy in the treatment of peri-implantitis. J Clin Periodontol 2002; 29:213-220.

Mombelli A, Lang NP. Antimicrobial treatment of peri-implant infections. Clin Oral Implants Res 1992; 3:162-168.Rosenberg ES et al. Microbial differences in two clinically distinct types of failures of osseointegrated implants. Clin Oral Implants Res 1991; 2:135-144.

Schwarz F et al. (2006a). Nonsurgical treatment of moderate and advanced peri-implantitis lesions: a controlled clinical study. Clinical Oral Investigations 10, 279–288.

Wadhwani C et al. A descriptive study of the radiographic density of implant restorative cements. J Prosthet Dent. May 2010; 103(5):295-303.


Apical peri-implantitis

An apicoectomy of the implant can be done as shown in JOI 2018 Manfro

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  1. Dental code cement sepsis | Bauer Dentistry & Orthodontics - July 19, 2016

    […] amount of bone damage that has already occurred.  The steps would be the same as the treatment of peri-implantitis and can be found on the previous link.  This method would be more favorable to those that do not […]

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