Peri-implantitis – Not on Your Shift! – Clinical Research Dental

Peri-implantitis – Not on Your Shift!

Dental implants have become a standard treatment option for the replacement of missing teeth. As they continue to become more popular, many patients are asking and requesting dental implant treatment to improve their overall dental esthetics, function, and phonetic abilities.

Overall, the survival rate of dental implants is considered to be high, however, the complication rates and the potential for disease around the implant are a growing source of concern. Many patients believe that implants require less cleaning and maintenance since they are not natural.

The truth, nevertheless, is exactly the opposite. The most common and challenging complication of dental implants is peri-implantitis. Peri-implant diseases are common biological complications of dental implant therapy, which may result in the failure of a dental implant. We, the clinicians, should understand the etiology and contributing factors of these common diseases.

Peri-implant Mucositis Vs. Peri-implantitis:

Peri-implant mucositis refers to an inflammation that is confined in the soft tissue attachment around a dental implant fixture. An implant with peri-implant mucositis often accompanies erythema and edema around peri-implant marginal mucosa, in addition to bleeding on probing. In comparison, peri-implantitis refers to an inflammation in supporting alveolar bone as well as the soft-tissue attachment, which results in irreversible destruction of alveolar bone.

In addition to the clinical signs of peri-implant mucositis, an implant with peri-implantitis may accompany suppuration, pain, and increased mobility. The loss of the supporting bone and attachment is irreversible. In the absence of treatment, peri-implantitis progresses in a “non-linear and accelerating pattern,” more rapid than the progression of periodontitis.

According to a meta-analysis, the prevalence of peri-implant mucositis is approximately 43% while that of peri-implantitis is 22%.1 Dental plaque is the most important etiologic factor for peri-implant diseases. Dental plaque accumulation at dental implants triggers the inflammatory response, leading to peri-implant mucositis and peri-implantitis. Patients with poor oral hygiene were found to exhibit approximately 15 times higher chance of developing peri-implantitis.1

FIG. 1
Radiographic view of implants with peri-implantitis.

FIG. 2
A 10 mm pocket on the buccal aspect of an implant with Peri-implantitis.

Tackling Peri-implant Mucositis/Peri-implantitis: In-office Protocols

Considering that the initiation of peri-implant diseases may be triggered by the presence of dental plaque similar to that of periodontal diseases, achieving and maintaining excellent plaque control is an important factor in prevention and treatment of peri-implant diseases. Based on the principles of cause related therapy, clinicians should educate their patients on how to effectively remove the potentially main etiologic factor — dental plaque around teeth and implants.

Implant treatment can be very expensive, time consuming, and even challenging in some cases. Thus, it is of paramount importance, that both dental professionals and our patients be well aware of the possible complications and the ways to prevent them. The patients’ current health status and risk factors should be identified during this stage and be addressed or minimized before the patient receives dental implants.

An integral part of dental implant related treatment plan should include meticulous home care and strict follow-up and maintenance protocols. This should be instilled in the patients prior to the implant placement to ensure that long-term health conditions can be maintained around the implant.
Prior to implant placement, oral hygiene instruction should be a big portion of the initial implant consultation. This includes demonstrating proper brushing and interdental cleaning techniques to the patient and ensuring that they understand the oral hygiene instructions at follow-up appointments. Patients should have to prove to the dental professional that they will be able to maintain the appropriate home care protocols prior to implant placement.

Regarding professional maintenance, patients are required to understand the increased recall regime that is needed to maintain their dental implants. The recall regime for patients is recommended to be approximately three to six months long, however, patients who present with risk factors should have a significantly shorter recall. Frequent recalls increase the ability of the dental professional to diagnose complications at the earliest state possible and has been shown to increase success rates of dental implants.

Evidence-based Implant Maintenance

Appropriate tools need to be recommended and demonstrated to the patient to show proper ways to remove all plaque surrounding the teeth and implants in the oral cavity. This should include proper brushing and inter-proximal cleaning as well.

Evidence showed that oscillating-rotating (OR) powered toothbrushes demonstrate more plaque removal capabilities while also reducing the number of bleedings sites better than other powered toothbrushes. In a meta-analysis by Grender et al, subjects with localized or generalized gingivitis had 7.4 times better odds of transitioning from gingivitis to a healthy state after using an electric OR brush versus a manual brush.

FIG. 3

Oral-B iO.

Compared to manual toothbrush users, electric toothbrush users showed a reduction in:

Table comparing the issues and the percentage reduced by the use of a power toothbrush

When evaluated on patients with dental implant, powered toothbrushes were found to be effective, safe, and comfortable for those rehabilitated by means of oral implant-supported prostheses.

FIG. 4

Oral-B iO Targeted Clean brush head for implant maintenance.

At the end of a 12-month study of 80 peri-implant patients replacing their manual brush with an oscillation-rotation brush, it was found that:
✓ The mean overall pocket depth decreased by 0.3 mm
✓ No gingival or mucosal ulcerations/desquamations were observed

Additionally, high user scores were given to the convenience and comfort of the powered toothbrush, with 95% indicating they would continue to use the powered brush. Therefore, it might be reasonable to recommend on oscillating-rotating (OR) powered toothbrushes for long-term dental implant maintenance and home care.

In many cases, the traditional inter-proximal cleaning methods such as string flossing are not user friendly for patients and do not provide the proper inter-proximal plaque removal. Thus, other inter-proximal cleaning aids should be introduced.

Furthermore, Stannous Fluoride (SnF2) dentifrices were shown to offer an advantage over traditional sodium fluoride toothpastes as they can reduce metabolic production of bacterial toxins, suppress pathogenic virulence, and promote bacterial and host symbiosis. The therapeutic effects of SnF2 were best demonstrated in a meta-analysis by Biesbrock A et al. who demonstrated 3.7x better odds of shifting from gingivitis to health vs. a negative control sodium fluoride (or MFP) toothpaste using Crest’s SnF2 formulation. Additionally, a specially formulated stabilized stannous fluoride dentifrice with antibacterial properties that is safe for titanium (Ti) implants, may provide patients with an enhanced home-care regimen for oral health. Figure 6 shows light microscopy and scanning electron microscopy (SEM) results for a 0.243% Sodium Fluoride (NaF) treatment and a 0.454% SnF2 treatment on Ti implants, verifying both are safe to use.

FIG. 5
Stannous Fluoride (SnF2) dentifrice.

Comparison of toothpastes in light microscopy

FIG. 6
Light microscopy and SEM results. St. John S, et al. AADR/IADR 2018. (Image courtesy of P&G).

Conclusion

As more dental implants are used to restore patients’ dentition, there is an increased chance of patients presenting with peri-implant diseases. If we, as dental professionals, fully understand the etiology of peri-implant diseases and the associated risk factors we will be better able to prevent the disease. This involves thoroughly educating patients and ensuring they understand the home care regime and maintenance recalls that are necessary to prevent peri-implant diseases. By using these strategies before and after dental implants are placed, we will be able to ensure implant success while also preventing the development of peri-implantitis.

REFERENCES

Kwon T, Yen HH, Levin L. Peri-implant disease: early diagnosis and non-surgical treatment—a narrative literature review. Frontiers of Oral and Maxillofacial Medicine 2022; https://dx.doi.org/10.21037/fomm-21-58.

Jepsen S, Berglundh T, Genco R, et al. Primary prevention of peri-implantitis: managing peri-implant mucositis. J Clin Periodontal 2015;42 Suppl 16:S152-7.
St. John S, Suszcynsky-Meister E, Shauchuk A, et al. Chemical effects of stannous and sodium fluoride dentifrices on titanium alloy surfaces. J Dent Res (AADR/IADR)2018;97 (Spec Iss A): Abstract 994.

Vandekerckhove B, Quirynen M, Warren PR, Strate J, van Steenberghe D. The safety and efficacy of a powered toothbrush on soft tissues in patients with implant-supported fixed prostheses. Clin Oral Investig. 2004 Dec;8(4):206-10.

Clark-Perry D, Levin L. Comparison of new formulas of stannous fluoride toothpastes with other commercially available fluoridated toothpastes: A systematic review and meta-analysis of randomised controlled trials. Int Dent J. 2020 Dec;70(6):418-426.

Kwon T, Wang CW, Salem DM, Levin L. Nonsurgical and surgical management of biologic complications around dental
implants: peri-implant mucositis and peri-implantitis. Quintessence Int. 2020;51(10):810-820.

Clark-Perry D, Levin L. Systematic review and meta-analysis of randomized controlled studies comparing oscillating-rotating and other powered toothbrushes. J Am Dent Assoc. 2020 Apr;151(4):265-275.

Biesbrock A, et al. The effects of bioavailability gluconate chelated stannous fluoride dentifrice on gingival bleeding: Meta- Analysis of eighteen randomized controlled trials. Journal of Clinical Periodontology; December 2019.

About the Author

Liran Levin, DMD, FRCD(C), FIADT, FICD

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This article was published in the Clinical Life™ magazine:

Spring/Summer 2026

Clinical Life™ magazine is a premier periodical publication by Clinical Research Dental Supplies & Services Inc. Discover compelling clinical cases from Canadian and US dental professionals, cutting-edge techniques, product insights, and continuing education events.

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