Peri-implantitis is an inflammatory reaction around dental implants that can lead to loss of supporting bone. It has two forms: peri-implant mucositis, which is reversible inflammation confined to soft tissues; and peri-implantitis, which involves progressive bone loss beyond initial remodeling. Risk factors include a history of periodontitis, smoking, residual cement, and implant position/design. Treatment includes non-surgical approaches like mechanical debridement and antibiotics, as well as surgical methods such as regenerative procedures and surface decontamination. The combination of systemic antibiotics, antiseptic mouthwash, and surgical debridement can improve outcomes, though no single surface decontamination method is superior.

1. Peri-implantitis
Thanwadee Immsombatti
Jan 8th,2014

2. Background
• Peri-implant disease : An inflammatory reaction around the tissue
surrounding an implant consist of two forms
• Peri-implant mucositis
• Peri-implantitis
Mombelli A. et al. Periodontol 2000 1998;17:63-76.
The Sixth European Workshop on Periodontoloy 2008

3. Peri-implant mucositis
• The presence of inflammation
• Confine to the soft tissue
• No signs of loss of supporting bone following initial bone remodeling
• Reversible condition : early intervention and remove etiology
San M. et al. J Clin Periodontol 2012;39(Suppl.12):202-206.

4. Peri-implant mucositis
• Clinical findings
• Bleeding on probing / gingival redness
• Probing depth ≥ 4 mm
• No radiographic bone loss
• Prevalence : 48% of implants
San M. et al. J Clin Periodontol 2012;39(Suppl.12):202-206.
Roos-Jansaker AM. J Clin Periodontol 2006;33:290-295.

5. Peri-implant mucositis

6. Peri-implantitis
• An inflammatory process
• Soft tissue inflammation, Bleeding on probing
• Probing depth ≥ 5 mm
• Suppuration

7. • Progressive loss of supporting bone beyond biological bone remodeling
• Mean crestal bone loss of 0.9-1.6 mm in first post-surgical year
• Then annual bone loss of 0.02-0.15 mm
• In case of no baseline radiograph, 2 mm vertical distance from expected marginal bone level
• Prevalence : varied from 11%-47% depending on the threshold used
Peri-implantitis
Koldlands OC. et al. J Periodontol 2010;81:231-238.
San M. et al. J Clin Periodontol 2012;39(Suppl.12):202-206.

8. Peri-implantitis

9. Etiologies
• Formation of biofilm
• Gram-negative anaerobic bacteria : similar to natural teeth in periodontal
disease
• Peri-implant mucositis – Gingivitis
• Peri-implantitis – Periodontitis : S.aureus could be found as the initiation of peri-
implantitis
Heit-Mayfield LJ. et al. Periodontol 2000 2010;53:167-181.
Leohardt A. et al. Clin Oral Implants Res 1999;10:399-345.

10. Factors associated Peri-implantitis
• History of periodontitis : two times
• Smoking : 3-4 times increased risk for peri-implantitis
• Residual cement : Rough area beneath gingival margin  Bacterial
attachment
• Implant position and design : inability to clean
Mombelli A. et al. Clin Oral Implants Res 2012;23(Suppl.6):67-76.
Linkevicius T. et al. Clin Oral Implants Res 2012 published online

11. Treatment
• Primary goals
• Resolve inflammation
• Arrest the progression of disease

12. Treatment

14. Non-Surgical treatment
• Mechanical debridement
• Ultrasonic scaler
• Hand instruments : Plastic curette
• Rubber cup & pumice
• Plaque control

16. • Effective in Peri-implant mucositis
• carbon fibers curette, rubber cup, pumice
• In peri-implantitis, mechanical debridement alone was found not to be
effective
Non-Surgical treatment

17. • Use in conjunction with mechanical debridement and chemical disinfection
• Local : high concentration, reduce side & adverse effect
• Tetracyclin HCL (Actisite® )
• Minocyclin
• Systemic : ornidazole 1000 mg daily, metronidazole, amoxicillin
Antibiotic

18. Antibiotic

19. Surgical approach
• Surgical approach
• Access surgery : apically positioned flap, surface modification
• Resective
• Regenerative : guided tissue regeneration, bone grafting
• Surface decontamination

22. Surface decontamination
• Chemical agents
• hydrogen peroxide, citric acid, 35% phosphoric acid
• Photodynamic therapy
• Photosensitizer + high energy laser light -> destroy bacterial cells
• Laser treatment
• combined with Chemical agents to archieve higher re-osseointegration

25. Anti-infective protocol
• Peri-implantitis VS Periodontitis
• Eiology
• Treatment
• Anti-infective protocol have been adopted to treat peri-implantitis
• Open flap debridement
• Implant surface decontamination
• Systemic antibiotic : Amoxicillin (500 mg) + Metronidazole (400 mg) 7-10 days

26. Anti-infective protocol

28. Conclusions
• Non-surgical treatment alone was found to be effective in peri-implant
mucositis : carbon fibers curette, rubber cup, pumice
• Peri-implantitis with mild bone loss : Mechanical debridement,
Antiseptic(CHX mouthwash), Systemic/Local Antibiotic, Resective surgery
• Peri-implantitis with moderate bone loss : Mechanical debridement,
Antiseptic(CHX mouthwash), Systemic/Local Antibiotic, Open flap
debridement, Surface decontamination, Regenerative surgery

29. Mechanical
debridement
Anti-septic
mouthwash
Local/systemic
antibiotic
Resective
surgery
Surface
decontamination
Regenerative
surgery
Peri-implant
mucositis
(<3mm)
Peri-implant
mucositis
(>3mm)
Peri-implantitis
with mild bone
loss
Peri-implantitis
with moderate
bone loss

30. Conclusions
• Bone fill & Re-osseointegraion
• Regenerative procedure > Open flap debridement
• Membrane did not improve treatment outcome in comparison to the use of
autogenous bone alone
• Systemic antibiotic (Amoxicilin plus metronidazole) and antiseptic mouthrinse(CHX) :
improved clinical outcomes

31. Conclusions
• No single method of surface decontamination(Chemical agents, air abrasive,
lasers) was found to be superior
• Citric acid(40%,30-60 sec) has proved to be most effective agent for bacterial
growth reduction on HA surfaces
• The simplest method of surface decontamination; gauze soaked alternately
in CHX and saline, should be preferred when combined with membrane-
covered autogenous bone graft