periimplant mucositis and periimplantitis

1. Current understanding of diagnosis, clinical
implication and treatment protocol of peri implant
mucositis and peri implantitis
CATEGORY 4: LIFE MEMBER OF ISP

2. 2
Contents
Introduction................................................................................................................3
Materials and methods...............................................................................................4
Etiopathogenesis and risk factors..............................................................................5
Diagnostic test for Peri-implant diseases..................................................................7
Clinical assessment.................................................................................................7
Radiographical assessment ..................................................................................12
Histological assessment........................................................................................13
Microbial assessment ...........................................................................................14
Biomarkers............................................................................................................14
Bone defects of PI ....................................................................................................16
Treatment plan for Peri-implant diseases ...............................................................18
Therapy of peri-implant mucositis........................................................................21
Peri-implantitis nonsurgical therapy ...................................................................22
Surgical therapy of peri-implantitis .....................................................................23
Evidence based outcomes for managing PID..........................................................27
Home-use oral-hygiene interventions......................................................................29
Prognosis..................................................................................................................31
Supportive peri-implant therapy (SPIT) ..................................................................32
Multifactor analysis for successful implant-tissue interface ...................................33
Clinical implication..................................................................................................34
Decision tree for managing PID..............................................................................35
Strength and limitation ............................................................................................36
Future possibilities...................................................................................................36
Conclusion ...............................................................................................................36
Reference..................................................................................................................38

3. 3
Introduction
“Failure is the stepping stone to promote all our success in the future
dental implant (DI) practice”.
This will promote most promising solution for the dental surgeon (DS) who are facing
complications in the DI procedures which includes biological, mechanical, prosthetic or material
failure and maintenance problem.1
The strategic success for the DI might include the peri implant
tissue (PIT) assessment which comprises both soft tissue (ST) or mucosa and hard tissue (HT) that
assessed during the preoperative and postoperative follow up.
The strong interface sustained between DI and their supporting PIT will provide a long
term success rate in the implant dentistry. The ST-implant interface creates a biological seal or
barrier around the DI to prevent future disease progression. While, the HT-implant interface
provides stability and rigidity for the DI. Any weak interface when observed between PIT and
implant surface (IS) could lead to peri-implant failures. Still, enumerable factors could be
contributed for this failure. Finally, the ST-implant interface and the osseintegration of the DI can
be affected to lead the adverse effect of peri-implant mucositis (PIM) or peri-implantitis (PI).
Currently, workshops and team force had defined PIM as an inflammatory lesion of the
mucosa surrounding an implant without any loss of supporting peri-implant bone and PI as a
progressive and irreversible disease of PIT accompanied with pocket formation, purulence and
bone resorption; thereby affecting the osseointegration.2,3
Peri-implant diseases (PID) such as PIM
and PI can be diagnosed and managed at an earlier, intermediate and advanced stage depending

4. 4
on the clinical outcome. Here is the review to reflect and contemplate the various protocols
available for the current diagnosis and treatment execution for managing the PID.
Critical assessment is made for the clinical implication that encountered commonly during
the implant practice.1
This gives us better knowledge and confidence for the DS to restore DI
practices from the path of failure to success. Thus, the future practice can be enhanced simply and
effectively by current understanding of PID and its management.
Materials and methods
A complete literature search was done on PubMed/Medline for articles available in English
language reviewing current understanding of diagnosis, clinical implication and treatment plan for PID
using the key terms: “Peri-implant disease, Peri-implant mucositis, peri implantitis, risk factor,
management and prognosis”. The relevant papers were chosen according to the inclusion and exclusion
criteria. Literature search revealed that most of the studies included were clinical studies, evidence
based reviews; systematic reviews and randomized controlled trial (RCT) [Chart 1]. All publications
focusing case report, case series, animal study model were excluded.
Chart 1: Study design
Total no. of articles searched using PID from 2000 to 2019= [1,611 results]
Total no. of articles met the inclusion criteria [Peri-implant disease, Peri-implant mucositis,
peri implantitis, risk factor, management and prognosis]
Total no of clinical studies- 161
Systematic reviews- 6
Meta-analysis-2
Reviews- 15
RCT-10

5. 5
Etiopathogenesis and risk factors
The microbial dysbiosis which is evident on the implant-tissue interface is not reflected as
the sole culprit for causing disease progression (figure 1). PIM and PI have multifactorial
etiologies. Rather, well established or any predisposing factor along with an emerging risk factors
could be involved to progress the PID (figure 2).
Peri-implant mucositis Peri-implantitis
Peri-implant health
Microbial factor
Polymicrobial synergy and dysbiosis
Bacterial shift spectrum - subject related
Cellular level
Homeostasis breakdown
Bone resorption
Etiology
Figure 1: Shift of Peri-implant health to disease spectrum
Molecular level
Pathogenesis: Host-immune interaction
PMN
Macrophage
Dendritic cells
B and T cells
Initiation of inflammation
Connective tissue
breakdown
IL-1b, 17,18
TNF-α
Cathepsins
Histamine
End result
Vasodilatation
Vasoconstriction
Peri-implant mucositis: similar to gingivitis
Inflammation progression
Gingival fibroblast ROS
Enzymes
MMPs
Inflammation progression
Permeability and
breakdown of tissues
Osteoblast
Osteoclast-PRECUSSOR
T-helper cell (Th-1, Th-17)
B cells
RANKL
Bone resorption by active
osteoclast cells thereby
disturbing an
osseintegration
Inflammation progression
Peri-implantitis: similar to periodontitis
Inflammation progression
Environmental/ Genetic/ Risk Factor

6. 6
Well-established risk
factors
Host related factors
Emerging risk factors
Predisposing factors
Age, gender, vitamin D, and autoimmune diseases
Bone quality, obesity, metabolic syndrome, parafunctional
habits, chemotherapy, radiotherapy, other systemic diseases,
genetic Predisposition and periapical pathology
Diabetes, Smoking, History of periodontitis and poor plaque
control, Excess Cement, Occlusal Overload, Keratinized
tissue
Peri-implant disease
Material related factors
Implant surface characteristics, and placement depth, titanium metal particles
Prosthetic related factors
Surgical related factors
Risk factors
Improper restorative design
Foreign Body Reaction around Implants
Operator experience, surgical trauma, incision design, aseptic surgical field.
When DI (titanium material) is placed in the bone, it will act as a foreign body in the living
tissues. This may lead to marginal bone loss due to immunological responses that created
within the body.5
Still it is under research

7. 7
Diagnostic test for Peri-implant diseases
Correctly diagnosing PID is essential for its effective management. PID if left untreated, can
affect osseintegration and leads to implant failure.2
Thus proper diagnosis at an earlier, mid-
course or advanced stage may help to save DI without its loss. This review aims to elaborate
current diagnostic aids for diagnosing PID such as PIM and PI (chart 2).
Instruments
Essential,, desired and optional
treatment strategy
Let us enlist the diagnostic aids:
Clinical assessment
The basic diagnostic methods used for detecting PIM and PI include clinical assessment.
It comprises specific instruments. It can be classified based on its applicable use as (figure 3)
 Essential instruments
Clinical
Radio
graphical
Biomarkers
Histological
Preventive diagnostic
aids
Current diagnostic
aids
Future diagnostic
aids
Chart 2: Diagnostic list for Peri- implant mucositis
Peri-implantitis
Microbial Genotype and
polymorphism

8. 8
 Desired instruments
 Optional instruments
DESIRED INSTRUMENTS
OPTIONAL INSTRUMENTS
Figure 3: Instruments for Peri-implant disease diagnosis 6
ESSENTIAL INSTRUMENTS
PERI-IMPLANT PROBES
PLASTIC PROBES TITANIUM PROBES
TORQUE RATCHET PERIOTEST MAGNETIC RESONANCE
FREQUENCY
DIGITAL MICROMETER LOUPES Intra oral camera

9. 9
Clinical steps involved for diagnosing peri-implant diseases
Visual method
Initially, the PIT can be assessed by a visual method of examination. This offers to evaluate
the subject oral hygiene status (OHS) and the detection of clinical conditions like redness or
swelling.7
This method offers a non-invasive mode of diagnostic examination.
Palpation
Next, the clinical manifestation around PIT can be assessed by palpation. It helps to
examine peri-implant site for bleeding, swelling or suppuration. This method offers a better
diagnostic measure over visual examination.8
Clinical indices
Plaque indices for implant
The commonly used clinical plaque indices are given by Lindquist et al. 9
in 1988 and
Mombelli modified plaque index (mPI) given by Mombelli et al. 10
in 1997. It helps to quantify
the plaque deposit over PIT.
 Degree 0= no plaque
 Degree 1= local plaque
accumulation
 Degree 2=Generalized plaque
accumulation >25%
Plaque index by Lindquist et al
Mombelli modified plaque index
 Grade 0= no plaque
 Grade 1=non visible thin film of plaque,
detected by scraping the tooth with a probe
 Grade 2=visible plaque
 Grade 3=massive plaque deposits which fill the
interdental space

10. 10
Gingival indices for implant
Gingival index (GI) for implant is given by Apse et al. 11
in 1991 and Mombelli modified
gingival index (mGI) given by Mombelli et al.9
in 1987 are the two indices used to assess gingival
status around DI.
Peri-implant probing (PP)
It is one of the basic and essential method to assess the PIT status. The probing force of
0.2N must be used for measuring the clinical parameters like peri-implant pocket depth (PD), BOP,
clinical attachment level (CAL) and mobility.12
Perhaps, it have good and negative diagnostic
accuracy for assessing the disease progression (table 1).
Table 1: Evidences supporting and criticizing PIPD, BOP and CAL for assessing Peri-
implant diseases 13
Supportive The sequential recording of PP over time might be a good indicator for
progression of disease activity.
Criticize  PP around DI is more uncomfortable and chance of creating PIT damage
with scar formation.
 Grade 0= no inflammation
 Grade 1= slight change in color
 Grade 2=erythema, edema, gingival
bleeding on probing (BOP)
 Grade 3=marked erythema, edema and
spontaneous gingival BOP
Mombelli modified gingival index Gingival index by Apse et al
 Degree 0= normal mucosa
 Degree 1= Minor inflammation with color
change and edema
 Degree 2=Moderate inflammation with soft
consistency of the mucosa, as well as redness
and edema.
 Degree 3=marked erythema, edema, and
spontaneous bleeding without probing.

11. 11
 May leads to over diagnosis when compared to probing around teeth
because of deeper penetration of probe into PIT. This is due to lack of
fibers running from cementum to teeth.
 Implant design (implant neck with convex form), texture (rough) and
coating with titanium plasma may hinder the PD
 Absence of BOP demonstrated a stable peri-implant conditions but
presence of BOP is not be a good indicator for disease progression. Even
it may rupture small blood vessels during PP.
 CAL is not as good indicator for measuring the disease progression until
the reference point is fixed.
 Clinical parameters cannot be used as good diagnostic accuracy for PIM
and PI.
Mobility/ stability measures
The mobility of the DI can be checked by the two rigid instrument moving it in a bucco-
lingual direction with a force of 500 g. An implant mobility scale from 0-4 is a clinical method of
grading the DI mobility given by Misch.14
The other non-invasive test to measure the stability of DI includes periotest and magnetic
resonance frequency analysis (RFA). In periotest, the score of −8 represents low mobility and +50
Scale Description
0 Absence of mobility with 500 g moving in any direction
1 Slight detectable horizontal movement
2 Moderate visible movement up to 0.5 mm
3 Severe horizontal movement greater than 0.5 mm
4 Visible Moderate to horizontal movement and visible vertical movement

12. 12
indicates severe mobility. Even it has disadvantages of poor sensitivity and resolutions.15
The RFA
measures implant stability (IS) with a range of 1-100 implant stability quotient (ISQ), where 100
means higher stability of DI. Osstell, an approved FDA device is used for assessing IS using
RFA.16
Still, many products are available in the markets to diagnose the IS.
Width of peri-implant keratinized mucosa (WPKM)
The minimum 2 mm of WPKM offers adequate ST-implant interface and resistance to any
damage around PIT. The adequate WPKM helps to prevent mucosal recession and peri-implant
attachment loss.17
Occlusal evaluation
The key success of DI depends on the occlusal status of the DI and its prosthesis.18
Thus,
occlusal overload due to premature contacts or interferences may lead to DI failure.
Percussion
It is assessed by taping the instrument handle which is placed at right angled or parallel to
the implant body. An osseointegrated DI indicate clear ringing or hypersonoric sound on
percussion. While, dull or hyposonoric sound is evident in PID. It is one of the simple test to assess
implant stability but vary on operator performance.15
Radiographical assessment
Preservation of crestal bone for long term is the most crucial entity for successful DI. Still,
the ultimate reason for crestal bone loss (CBL) are under debate. Some consider CBS as a normal
phenomenon occurring due to foreign body reaction around DI or even after prosthetic loading.5
The periapical radiographic technique (PRT) is an essential diagnostic method to monitor the CBL
at baseline and annually. The use digital subtraction radiography (DSR) or cone beam computed

13. 13
tomography technique (CBCT) may improve the diagnostic accuracy for assessing peri-implant
disease.19
Histological assessment
Light microscope findings
 The epithelium shows more infiltration of polymorphonuclear neutrophils (PMNS) and
mononuclear cells.
 The connective tissue (CT) consists of macrophages, lymphocytes and plasma cells.
 Additionally PI shows inflammatory cells infiltration that extended apical to the pocket
area and reach the bone.20
Electron microscope findings
 Bacterial accumulation is evident in the desmosome region. Collagen fibers and fibroblast
cells in the CT are replaced by the inflammatory cells.
 Alteration and congestion of the blood vessels are evident.
 More PMNS are infiltrated around the epithelium, CT and bone suggesting the
inflammatory progression around the DI leading to PI.20,21
Radiographic Criteria for assessing PID
The reference point for standardized radiographic geometry is considered either from
an implant shoulder or apex.
Annual record of radiographs must be taken to rule out PID. Annual CBL of less than
0.2 mm after first year of implant placement is one of the successful criteria for DI.
For diagnosing PI, radiographic changes are to be noted.
Note: cup shaped or crater like CBL around HT-implant interface may indicate PI.
Radiolucency around implant indicate overload of implant.

14. 14
Thus, it is considered as an invasive method and mainly used for research purposes. It need
surgical procedure for tissue examination which is technique sensitive and expensive for
laboratory analysis.
Microbial assessment
Despite the clinical and radiographical findings, microbial examination creates a
synergistic role for diagnosing peri-implant diseases. It includes bacterial culture, PCR technique,
checkerboard DNA-DNA hybridization, and 16S rRNA gene sequencing technique. The main
disadvantage on using this advanced microbial test needs a selective DNA probe for bacterial
species identification which is technique sensitive and expensive.22
Biomarkers
Biomarkers may offer better diagnostic accuracy for PID. Peri-implant crevicular fluid
(PICF) and saliva can be used as a biomarker to diagnose the PID. They are higher levels in
diseased site when compared to healthy implant. PICF can be collected using paper strips or micro-
capillary pipettes. PICF can be estimated using Enzyme-linked immunosorbent assay (ELISA),
flow cytometry, Luminex and Spectrophotometry.
Table 2: Biomarkers in PID assessment 23
Biomarkers
Cytokines
 TNFα
 IL-1β
 IL-10
Enzymes
 MMP-8
 MMP -9
 MMP-13
 Myeloperoxidase
 Elastase
 Cathepsins
 TIMP-2
Bone markers
 Osteocalcin
 sRANKL
 RANK
 OPG

15. 15
Chair side test or point of care and multi biomarker approach are the best markers used to
detect PID. MMP-8 (ImplantSafe®) is one of the rapid chair side test used to diagnose PI when its
level is greater than 20 ng/mL. IL-17, IL-1ra and VEGF are used as a multi-biomarker analyser
to detect PI. Still, longitudinal assessment for each subject is needed to diagnose PID status and it
is very expensive. 23
Outline of current diagnostic aids for PID
Diagnostic criteria PIM PI
Reversible + -
Plaque accumulation + +
Gingival inflammation + +
pain - +
BOP + +
PD + +
Mucosal recession _ +
Bone loss - +
Implant mobility - +
Evidence based systematic review for diagnosing PID
Study Author year Remarks
Diagnostic
Principles of PI
Ramanauskaite
et al 24
2016 Based on ST status and the amount of bone loss.
BOP-diagnosis of PI Hashim et al 25
2018 BOP positive implants- 24.1% chance for diagnosing PI.
BOP positive patient-33.8% chance. False-positive rate of BOP
can wrongly predict to diagnose PI
PICF assist in the
diagnosis of peri-
implantitis
Faot Fet al 26
2015 IL-1β and TNF-α- additional criteria for a more robust diagnosis
of PID.
Microbial profiles Sahrmann et al
27
2020 Does not show specific microbial profile. Evidence of
Actinomyces spp, Porphyromonas spp, and Rothia spp in PID sites
compared to peri-implant health.

16. 16
Bone defects of PI
Based on Schwarz et al (2007),28 bone defects for PID is classified as
 Class I- Intra-osseous component (divided into 5 classes)
 Class II-supra-alveolar component
Class I- Bone defects
Class Ia Buccal/lingual dehiscence defects with position of
the implant body within or beyond the envelope
Class Ib Buccal/lingual dehiscence defects with semicircular
bone resorption to the middle of the implant body
Class Ic Dehiscence defect with circular bone resorption under
maintenance of the buccal or lingual compact layer
Class Id Circular bone resorption with buccal and lingual bone
loss of the compact layer

17. 17
Class Ie Circular bone resorption with maintenance of buccal
and lingual bone of the compact layer
Based on number of bone present around implant, Renvert et al, 29 classifies
Radiologic classification for bone loss defect (Spikermann H, 1984)30
Class I Horizontal bone resorption
Class II Patelliform bone resorption
Class III
Class III A
Class III B
Funnel form bone resorption
Gap form bone resorption
Class IV Horizontal-circular form
Classification bony defects adjacent to dental implants (Vanden et al, 2004) 30
 Closed defects- presence of intact surrounding bone walls
 Open Defects -lack one or more bone walls.
This classification system helps in planning the regenerative procedure for each type of defect.
Four wall defect Three wall defect Two wall defect One wall defect

18. 18
Treatment plan for Peri-implant diseases
A proper clinical protocols are unavailabe to treat PID. The treatment response may differ
based on the subject clinical response, radiographic findings and risk factor. Broadly, the traetmnet
for PID includes non-surgical therapy (NST), surgical therapy and home care maintance. Similar
to gingivitis, PIM can be managed by NST and home care maintance. While, PI, which is similar
to periodontitis can be treated by combination of NST, surgical therapy and home care maintance.
If NST therapy fail to treat PI, deecontamination with surgical therapy like resective or
regeneration technique helps to resolve the inflammatory status of the disease.
Treatment decision for PID
It is classified based on
 Professional intervention
 Home-use oral-hygiene interventions
Professional intervention
Based on professional intervention, the therapy for PID is categorized into three segments of
Based on its clinical application and home care maintenance products, the armamentarium can be
classified (figure 4).
Therapy of peri-implant mucositis
Nonsurgical therapy of peri-implantitis
Surgical therapy of Peri implantitis

19. 19
Figure 4: Armamentarium for managing PID 31-33
PROFESSIONAL USE
ESSENTIAL
NON-SURGICAL THERAPY
SURGICAL THERAPY
REGENERATIVE THERAPY
DESIRED
MODIFIED AND PLASTIC
TIP
SCALERS
CARBON FIBRE
CURETTES
TITANIUM PLASTIC
DIAMOND BUR TITANIUM BRUSH SURGICAL KIT
BONE GRAFTS MEMBRANES PRF KIT
Vector system Laser
Air abrasive system

20. 20
OPTIONAL
ANTIBIOTICS
HOME CARE USE
Microsurgery Peizo surgery
Local drug delivery
Systemic
Interdental aids Powered tooth brush
Water irrigation Local chemotherapeutics

21. 21
Therapy of peri-implant mucositis
The aim of therapy is to remove the plaque deposits and inhibiting the bacterial re-
colonization on the implant surface (IS). Thus, it can improve the clinical parameters and prevent
the disease progression to PI. The step of PIM therapy involves
Mechanical debridement (MD)
Both supra and subgingival debridement of the IS, the implant neck (IN) and abutment can
be done using curettes (table 3), ultra sonic scalers which is made of polyether-etherketone-coated
tips or modified metal tip (cavitron), polishing brushes and air abrasive systems (figure 4).
Table 3: Curettes and its uses 33
Curettes Hardness Brittleness Efficacy
Carbon-fiber soft Easily break Remove bacterial deposits
without damaging the
surface
Teflon Soft Same as carbon -fiber Efficient when used with
air-abrasive systems
Plastic soft Most fragile Limited capacity
Titanium-coated hard Most resistant Can be used because it
will not scratch IS
Adjunctive antimicrobials
The antimicrobials act as an adjunct for PIM therapy. It is explained in the below table 4.

22. 22
Table 4: Application, method and efficacy of antimicrobials for treating PID 33
Types Antimicrobials Application Efficacy
Antiseptics Chlorhexidine (CHX) is
applied after mechanical
debridement in full mouth
disinfection protocol.
Application of 0.1% CHX gel
subgingivally
Brushing the tongue with 0.2%
CHX spray
Rinsing 0.2% CHX
mouthwash
Highly efficient
Locally
delivered
antibiotics
Tetracycline fibers (25 %
weight)
Microencapsulated
minospheres (arestin)
Doxycycline
It was circularly placed around
implants. Then, cyanoacrylate
adhesive was applied at the
mucosal margin. Initially, it
was placed for 7 days and
changed with another fiber.
After 10 days, it was removed.
Placed directly over the site of
infection.
Found to be
efficient.
Systemic
antibiotics.
Amoxillin-clavunate
Metronidazole
Clindamycin
Spiramycin
Clarithromycin
Cephalexin
Orally, 2 to 3 gm of amoxillin
can be given one hour before
surgery.
Can use antibiotics for 7 days
postoperatively.
No greater
efficacy is
observed.
May reduce the
chance of DI
failure.
Can used as
prophylaxis
Peri-implantitis nonsurgical therapy
It improves the clinical parameter of BOP and PP. It prevents further disease progression. The
sequential treatment mode for mild to moderate stage of PI includes
I. MD+ antimicrobial
II. Application of glycine based air abrasive systems

23. 23
III. Use of vector system creates vertical vibration of the working tip parallel to the
IS to render effective cleansing action.
IV. Erbium doped yttrium aluminium garnet laser is more efficient when compared
to diode laser.
V. Use of photodyamnic therapy: Diode laser with a power density of 100 mW must
keep in each pocket for 10 s after dye application (phenothiazine chloride dye or
methylene blue), followed by 3% hydrogen peroxide irrigation.
Surgical therapy of peri-implantitis
The ultimate aim for treating advanced PI includes thorough cleaning of the IS and some
modification of the ST and HT-implant interface to create re-osseointegration. The steps for
treating advance stage of PI includes
 Decontamination of the IS
 Surgical techniques
Decontamination of the IS
IS can be decontaminated using mechanical, chemical and laser approaches.33
Mechanical Curettes
 ultra sonic scalers made of
polyether-etherketone-
coated tips
 polishing brushes
 air abrasive systems
Implantoplasty
Smoothening of the rough IS to
make non retentive plaque
deposit.
Done using stones, burs.
Remove soft and hard deposits
on the IS.
Effective but contamination
with titanium particles is
evident.
Chemical Citric acid, hydrogen peroxide,
CHX and/or saline
Similar results. Even saline
showed better results.

24. 24
Lasers Erbium lasers yielded promising
results.
Surgical techniques
The ultimate aim of surgical technique is to expose the affected area for cleaning and
decontamination the IS (figure 5 and table 6). It includes
Table 5: Various modalities of surgical techniques
Access flaps
Apically repositioned flaps
Resective surgical techniques
Regenerative techniques
Esthetic surgeries for augmenting PIT
Surgery Procedures Advantages Indication References Figures
Access
flaps
Intracrevicular
incisions are
made.
Flaps are raised
Degranulation of
the peri-implant
inflamed tissues
is done.
Then, the flap is
positioned to the
original level
and the suture is
placed.
Maintain the
ST margin
around IN
Shallow
bone defect.
Figuero et
al.33

25. 25
Apically
repositione
d flaps
Reverse beveled
incision given.
Vertical
releasing
incision given to
position the flap
apically.
Then, the flaps
are raised
Then, cleaning,
decontamination
is done.
Followed by
osteoplasty
procedure which
is done using
bone chisel.
Then, the flap is
positioned
without covering
the affected part
and the suture is
placed.
Enhance self-
performed
oral hygiene
Reduce the
pockets
around the
affected
implants
Suprabony
defects
One-wall
intrabony
defect.
Non esthetic
areas
Figuero et
al.33
Resective
osseous
surgery
Intracrevicular
incisions are
made.
Flaps are raised
Degranulation of
the peri-implant
inflamed tissues
is done.
Both osteoplasty
and osteotomy
must done.
Then, the flap is
positioned and
Reduction of
peri-implant
pocket depth.
Suprabony
defects
Non esthetic
areas
Romeo et
al.34
Serino et
al.35

26. 26
the suture is
placed.
Regenerati
ve
technique
Intracrevicular
incisions are
made.
Flaps are raised
Degranulation of
the peri-implant
inflamed tissues
is done.
A bone graft is
placed around
the implant, by
filling the
intrabony
component of
the defect.
After the bone
graft placement,
the membranes
are positioned
and stabilized.
Later, the flaps
are coronally
positioned and
sutured.
To support
the tissue
dimensions
Avoiding
recession of
the mucosa.
Makes re-
osseintegratio
n
.
Circumfere
ntial bony
defects with
intact bony
walls
Intrabony
defect
Roos-
Jansåker et
al.36
Schwarz et
al.37
Esthetic
surgeries
for
augmentin
g PIT
Mucosal
recession around
implant can be
augment using
Pedicle grafts
 Laterally
positioned
flap
 Double
pedicle flap
.
No second
surgical site
for pedicle
graft.
Implant soft
tissue
dehiscences
.
Thin soft
tissue
around
implant.
Basegmez
et al.38
Zucchelli et
al.39

27. 27
Evidence based outcomes for managing PID
Managing PI is a complex and dynamic process which often involves combination therapy (table
7).
 Oblique
rotational
flap
 Coronally
advanced
flap (CAF)
Free soft tissue
grafts
 Free
gingival
grafts
(FGG)
 Subepitheli
al
connective
tissue graft
(SCTG)
Other peri-
implant
procedures
Vestibuloplasy
Frenectomy
Increase the
width of
keratinized
tissue
Minimal
width of
keratinized
tissue.
Mucosal
recession
around
implants.
Abnormal
frenum
attachment.
Shallow
vestibule.
Papillary
deficiency
around
implant.
PIM PI
Combination therapy
Simple therapy

28. 28
Table 6: Various modalities of treatment for managing PI with evidence based review
Outcomes References33
Mean PP (mm) BOP
baseline final
Non-surgical
techniques
Titanium curettes + glycine-based air
abrasive + diode laser or local
minocycline
Carbon-fiber curettes +
chlorhexidine or local minocycline
Plastic curettes + chlorhexidine or
Erbium-doped yttrium aluminium
garnet laser- Moderate
Plastic curettes + chlorhexidine or
Erbium-doped yttrium aluminium
garnet laser- advanced
Carbon-fiber curettes
Ultrasonic device
Plastic curettes
Plastic curettes+ doxycycline
4.8
3.9
4.5
6.0
6.2
5.8
5.6
5.8
3.8
3.5
4.2
5.5
6.2
5.8
5.6
4.49
Improved
Improved
Improved
Improved
No change
Schar et al
Renvert et al
Schawrtz et al
Karring et al.
Buchter et al.
Surgical
treatment
Decontamination Surgical
procedures
Plastic curette +
saline
or
Erbium-doped
yttrium
aluminium
garnet
Laser
Access flap
surgery +
implantoplasty +
BioOss +
resorbable
membrane
6.2
4.9
3.5
3.8
Improved
Improved
Schwarz
et al.
0.2%
Chlorhexidine +
Access flap
surgery +
autologous bone
6.4 2.9 Not
reported Khoury &
Buchmann

29. 29
citric acid
hydrogen
peroxide + 0.9%
saline
Access flap
surgery +
autologous
bone+non
resorbable
membrane
Access flap
surgery +
autologous
bone+ resorbable
membrane
6.7
6.4
2.9
5.1
Not
reported
Not
reported
From the above table it is clear that no treatment modality have showed superior results
when compared to each other. The surgical technique with graft substitutes have shown better
results with use of any decontamination agents.33
Home-use oral-hygiene interventions
Long-term success of DI depends on oral hygiene maintenance of the patient. Various
home care products are available for the patient to enhance their oral hygiene status (figure 4).
Based on home use oral-hygiene interventions for maintaining PID
Mechanical plaque control
It involves use of
 Manual or powered toothbrushes
 Interproximal aids.
 Water irrigation
Mechanical plaque control
Chemical plaque control

30. 30
 Intraoral camera
Recommendations 33
Chemical plaque control
It act as an adjunct to manual plaque control by proving additional benefits.
Recommendations 33
Manual brush must be used for 30s - twice daily
Specialized implant dental floss and end-tuft brushes or interproximal brushes should used as
interdental aids.
Powered toothbrush: works on three-dimensional brushing action. It works on coupling sonic frequency
and oscillation with high-speed. It helps to clean the deeper part of PT.
Another powered brush called counter rotational brush works on the coupling principle of oscillating,
vibrating or acoustic modes of action. It helps to provide better cleansing property.
0.3%triclosan/copolymer
toothpaste
0.243% sodium fluoride silica-
based toothpaste
Listerine
CHX rinse
Probiotics therapy
60 s each
time
30 s each time

31. 31
Prognosis
Understanding the prognosis system in the field of implant dentistry help DS to evaluate
and manage the PID. It is considered as a tool for executing the appropriate diagnosis and treatment
plan for all stages of PID. Based on the level of bone loss, PD, mobility, BOP, and suppuration,
the prognosis system is classified as favorable, questionable, unfavorable, and hopeless.40
Favorable
Questionable
Early Peri implantitis
 Bone loss ≤1/4 implant
 PD ≥4 mm
 BOP/Suppuration
 No mobility
Treatment: Non-surgical therapy- Success likely
Moderate peri implantitis
 Bone loss 1/4-1/2 implant
 PD ≥6 mm
 BOP/Suppuration
 No mobility
Treatment: Non-surgical therapy+ surgical treatment
Success probable

Favorable
Peri-implant mucositis
 No bone loss
 PD <4 mm
 BOP/Suppuration
 No mobility
Treatment: Non-surgical therapy- Success likely

32. 32
Supportive peri-implant therapy (SPIT)
It can be decided based on the severity and extent of the PID. It involves both clinical and
the radiographic assessment. SPIT measures the protocol of therapeutic sequences based on their
disease criteria including clinical and radiographical interpretation.41
It includes
 Cumulative Interceptive Supportive therapy (CIST) 42 - classified into four stages: A,
B, C, and D.
 AKUT‑concept modified by Lang et al in 2004.
Still, proper supportive treatment methods are unavailable to manage and prevent PID. It is more
complex for the DS to follow and replicate in their daily practice. Here is the chart 3 to understand
current concept about SPIT.
Unfavorable
Hopeless
Advanced peri implantitis
 Bone loss >1/2 implant
 PD ≥8 mm
 BOP/Suppuration
 No mobility
Treatment: Non-surgical therapy+ surgical treatment or
extraction and redevelop site
Success unlikely
Advanced peri implantitis
 Bone loss >1/2 implant
 PD ≥8 mm
 BOP/Suppuration
 Mobility present
Treatment: Extraction leads to implant failure
NO success

33. 33
Chart 3: Model of SPIT
Multifactor analysis for successful implant-tissue interface
No single entity can be used to assess the success of the DI. Many factors are involved to
maintain both ST and HT-implant interface to prevent future PIM and PI. They are enlisted below:
PPD ≤3 mm
BOP present or negative
Plaque present
Clinical parameters
PPD, BOP, PI
Radiographic parameters
Bone loss
PPD 4-5 mm
BOP present
Plaque present
PPD ≥5 mm
BOP present
Plaque present
Treatment measures
No bone loss Non-surgical therapy
Professional based intervention:
Mechanical debridement
 Scaling and polishing
Adjunctive antimicrobials
 Systemic antimicrobial
 Local drug delivery
Home care intervention:
 0.1% CHX twice daily use
for 3-4 weeks
Peri-implant mucositis
No bone loss
Peri-implantitis
Bone loss >2 mm
Bone cratering ≤ 2mm
Circumferential
Non-surgical therapy+ surgical
therapy (decontamination,
surgical techniques either
resective or regeneration.

34. 34
Clinical implication
To date, PIM and PI differ with respect to diagnosis and treatment plan. At early stage,
PIM and PI can be treated successful by NST. While, moderate to advanced stages of PI can be
treated by various surgical modalities. No proper evidence is available for effective treatment
options. 43
Still, periodic recall visit and SPIT is needed to provide long term success of the DI.
Succesful
criteria to
prevent PID
Proper
diagnostic
assessment
Risk factor
identification and
elimination
Prognostic
factor
Supportive
periodontal
thrapy
Succesful
criteria to
prevent and
mange PID 44
• Association of risk factors with developing PID must be
identified and eliminated at an early stage
• Radiographic evaluation at baseline during implant placement
is mandatory
• Evaluate both clinical parameter and radiographic findings at
baseline during final prosthesis insertion
• Motivate, employ and monitor the OHS of the patient at
regualr recall visit
Knowledge about inflammatory complications as a part of an
implant treatment can be expected
• Early diagnosis and intervention of disease can lead to effective
management of PID

35. 35
Decision tree for managing PID
Peri-implant mucositis
Peri implantitis
Multifactorial considerations
Diagnosis
Etiology
Pathogenesis
Risk factor
History of
periodontitis
Patient
compliance
Treatment Plan
Non-surgical therapy
Non-surgical
therapy
Surgical
therapy
Maintenance
SPIT
Decontamination
Implantoplasty
Access flap/Resective/Regenerative
surgery
Mucosal augmentation procedure
around PIT
Laser therapy
Photodynamic
therapy
Figure 5: Decision tree for PID

36. 36
Strength and limitation
The current concepts of diagnosis, clinical implication and management of PID have been
explained in a specific and sensitive manner. To date, many protocols are mentioned to manage
PIM and PI. Here, we consider current protocols for diagnosing and managing the PID.
Future possibilities
Conclusion
Currently, understanding the diagnosis, treatment plan and clinical implication for
managing PID have been shown us more convincing results without encountering any possible
failures. Still, clinical and radiographic diagnosis are considered as a gold standard sensitive and
specific test for PID.
The respect of treatment may vary depending on the clinical situation of PID. PIM found
to have favorable prognosis and effective results, While, PI can be managed effectively at early
diagnosis. It need decontamination, IS alteration and surgical procedure (regenerative technique
including bone grafts and membrane are more effective) if NST fails to resolve the inflammation.
Future diagnostic aids
Oral Microbiome
Genetic polymorphism
Nutrigenomics
Metabolomics
Point of care/ chair side kit
Future treatment plan
Personalized Implant therapy
Recombinant growth factor
Tissue engineering in soft and hard
tissue achievement
Rapid prototype technique for soft and
hard tissue printing

37. 37
SPIT for long term follow up provides a comprehensive PIT evaluation and patient OHS
motivation to lead a successful implant survival without any failures. Even future innovation will
be a card for success.

38. 38
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