Peri-implantitis is an inflammatory disease affecting tissues surrounding dental implants, characterized by bone loss. It is caused by bacterial infection from periodontal pathogens like Porphyromonas gingivalis. Risk factors include a history of periodontitis, smoking, poor oral hygiene and occlusal trauma. Diagnosis involves assessing bleeding, suppuration and bone loss clinically and radiographically. Treatment may involve non-surgical approaches like antibiotics and cleaning, or surgical therapies like resection and regeneration to reduce bone loss and support tissue reattachment. Preventative maintenance through professional cleanings and addressing risk factors is important to avoid peri-implantitis.

1. SUCCESS IS AN ICEBERG

2. Peri-implantitis

3. Contents
Introduction
Peri-implant diseases
Classification of Peri-implantitis
Etiology
Prevelance
Risk factors
Pathology
Histopathology
Diagnosis
Prevention
Treatment
Conclusion
References

5. A Dental Implant is a prosthetic device made of
alloplastic material(s) implanted into the oral
tissues beneath the mucosal or periosteal layer
and on or within the bone to provide retention and
support for a fixed or removable dental
prosthesis.

6. Peri-implant mucosa Physiological periodontium
Desmosomes and hemidesmosomes of epithelium and junctional epithelium
(biological width) are linked with the contact surface
Direct bone-to-implant contact
Anchoring system of root cementum,
alveolar bone and desmodontic
fibers
Subepithelially more collagen fibers
and less fibroblasts/vessels
Subepithelially more fibroblasts and
vessels
Parallel collagen fibers in relation to
implant surface
Dentogingival, dentoperiostal,
circular and transseptal fiber
orientation
Comparison of peri-implant mucosa with physiological periodontium
PERPENDICULAR FIBERS
ANCHORING SYSTEM
CONNECTIVE TISSUE
FIBERS PARALLEL TO THE
IMPLANT
EPITHELIAL ATTACHMENT
IN CONTACT WITH THE
IMPLANT

7. Periimplant
Mucositis
• A Disease in which the presence of inflammation is
confined to the soft tissues surrounding a dental
implant with no signs of loss of supporting bone
beyond biological bone remodelling.
Peri-
Implantitis
• It is a progressive and irreversible inflammatory
disease of implant-surrounding hard and soft tissues
and is accompanied with bone resorption, decreased
osseointegration, increased pocket formation and
purulence.
PERI-IMPLANT DISEASES
POCKET FORMATION
BONE RESORPTION

9. Staging Definition
Stage I BoP and/or SUP and bone
loss ≤ 3 mm beyond
biological bone remodeling
Stage II BoP and/or SUP and bone
loss > 3 mm and < 5 mm
beyond biological bone
remodeling
Stage III BoP and/or SUP and bone
loss ≥ 5 mm beyond
biological bone remodeling
Stage IV BoP and/or SUP and bone
loss ≥ 50% of the implant
length
*
beyond biological
bone remodeling
BoP = bleeding on probing; SUP = suppuration
* Depending on implant length, if peri-implantitis can be classified as simultaneously
corresponding to more than one stage, the most advanced stage should be chosen.
PROPOSED CLASSIFICATION OF PERI-IMPLANTITIS

10. ETIOLOGY OF PERI-IMPLANTITIS
 Periodontal Pathogens
 ExcessiveTrauma – RETROGRADE PERI-IMPLANTITIS

11. Bacterial flora which are associated with periodontitis and peri-implantitis, are
found to be similar.
Studies have shown that the bacterial flora at the failing implant sites consist of
gram-negative anaerobic bacteria:
Prevotella intermedia
Prevotella nigrescens
Fusobacterium
Streptococcus constellatus
Aggregatibacter actinomycetemcomitans
Porphyromonas gingivalis
Treponema denticola
Tannerella forsythia
Peri-implantitis is a poly-microbial anaerobic infection
PERIODONTAL PATHOGENS

12. FACULTATIVE
ANAEROBIC COCCI
FACULTATIVE
ANAEROBIC RODS
GRAM ‘-’ve
52.8% 17.4% 7.3%
No Gingivalis and Spirochetes present
COCCOID MOTILE RODS SPIROCHETES
NATURAL
TEETH[CREVICES]
55.6% 4.9% 3.6%
PARTIALLY
EDENTULOUS
PATIENTS[IMPLANT
POCKETS]
65.8% 2.3% 2.1%
FULLY EDENTULOUS
PATIENTS
71.3% 0.4% 0
Implants in partially edentulous patients appear to be at a greater risk than
in fully edentulous patients

13. RETROGRADE PERI-IMPLANTITIS
 An infection at the apex of an implant deep in the bone.
 Fortunately such an infection is rare but it usually occurs very soon after implant
placement, typically within the first 3 weeks and results in an intense throbbing pain.
 ORIGIN : Chronic tooth abscess
Implant placement in freshly extracted socket
 No response to strong antibiotic therapy.
 Surgical decontamination is necessary.

14. RISK
FACTORS
Occlusion and
bone loss
Genetic
factors
Smoking &
oral hygiene
Parafunctional
habits
Iatrogenic causes
History of
periodontitis
Surface
modifications
of implant
Improper
prosthetic
design

16. PREVELANCE
There are several reports on the prevalence of mucositis and peri-implantitis
that differ between 5% and 63.4%. This enormous range is mainly based on
varying study designs and population sizes with different risk profiles and
statistic profiles
Zitzmann et al.
•patients with a
history of
periodontitis
•10% to 50% of the
dental implants
showed signs of
peri-implantitis
Consensus Report of
the Sixth European
Workshop in
Periodontology, Lin
dhe & Meyle
•incidence of peri-
implantitis
between 28% and
56%
Mombelli et al.,
•peri-implantitis in
20% of all
implanted
patients
•10% of all
inserted implants

17. Peri-implantitis with increased probing depth
(12 mm).
PERI-IMPLANTITIS - PATHOLOGY
[Peri-around,Implant,Itis-inflammation]
Clinical features:
 Bleeding on probing
 Redness
 Edema
 Suppuration
 Increased Probing depth
 Mobility
 Radiographical bone loss
Pain is an unusual feature, which, if present, is usually
associated with an acute infection.
SUPPURATION

19. DIAGNOSIS OF
PERI-IMPLANT DISEASES

20. DIAGNOSTIC PARAMETERS
 Clinical Indices
 Peri-implant probing using a rigid plastic probe
 Bleeding on Probing[BOP]
 Suppuration
 Mobility
 Peri-implant radiography
 Microbiology

21. PREVENTION OF PERI-IMPLANTITIS
Attention has to be paid, in particular to the following:
1. Refrain from smoking
2. Stay healthy
3. Maintain oral hygiene
By using mechanical plaque control (with manual or
powered toothbrushes)
Regular check upsNumbers of check-ups (cu) annually for different patient collectives
cu = 1 cu = 2 cu > 3
Oral hygiene and
hygienic ability of
the implant
well middle bad
Smoking status / in history in presence
Periodontitis,
mucositis (with
history)
/ / in presence
Other risk factors / /
e.g. systemic
diseases, history
of an non-
successful implant
insertion

22. Management of peri implantitis

24. Non-Surgical
[Conservative]
Manual
Treatment
Drug Therapy
Laser Therapy
Photodynamic
Therapy
Surgical
Resective Therapy
Regenerative
Approaches
The procedures include:

25.  Basic manual treatment can be provided by teflon-, carbon-, plastic- and
titanium curettes
 Material of the tip should be softer than titanium
 It is possible to reduce bleeding on probing scores by cleaning
with piezoelectric scalers as well as with hand instruments.
MANUAL TREATMENT:
CONSERVATIVE THERAPY
The use of a carbon
curette
Detoxification using an air
polishing device with glycin
powder.

26. Qualitative effectiveness (x: yes/o: no) of different cleaning methods depending on implant surface
Smooth surface
Sandblasted and acid-etched surface
(SLA)
Plasma sprayed surface
Rubber cap o o o
Metalic curette, rotating
titanium brush
o x x
Plastic curette o o o
Ultrasonic systems with
metalic tips
x (polished)
Ultrasonic systems with
plastic tips
o x x
Air polishing x x x
The results of air polishing systems are depending on the used medium and are significantly
better in the following order:
Hydroxylapatite/tricalcium phosphate > hydroxylapatite > glycine > titanium dioxide
> water and air (control group) > phosphoric acid
 An abrasive air polishing medium can modify the surface of implants
thereby:
Reducing the pocket depth and bleeding on probing
Re-osseointegration of titanium implants (39%-46%)
Increaisng clinical implant attachment
Reduction in pocket depth

27. DRUG THERAPY:
The following therapies can be distinguished:
 Antiseptic rinses in relation to different parameters.
 Application of systemic and locally delivered antibiotics in
relation to pocket depth or different parameters.
Systemic and Local Antibiotics:
A. Tetracyclines
B. Doxycycline
C. Amoxicillin
D. Metronidazole
E. Minocycline
F. Ciprofloxacin
G. Sulfonamides+Trimethoprim

28. Antibiotic Resistance
Clindamycin 46,7%
Amoxicillin 39,2%
Doxycycline 25%
Metronidazole 21,7%
Amoxicilin & metronidazol 6,7%
Antibiotic resistance of Prevotella intermedia , Prevotella
nigrescens and Streptococcus constellatus
New methods:
Metronidazole release from Poly-ϵ-Caprolacton/Alginat-ring - Lan et al
Fluorouracil release from Poly-ϵ-Caprolacton ring – Hou et al

29. LASER THERAPY:
Following lasers have bactericidal mode of action
o CO2
o Diode-, Er:YAG- (erbium-doped: yttrium-aluminum-garnet)
o Er,Cr:YSGG- (erbium, chromium-doped: yttrium-scandium-gallium-garnet)
lasers
LAPIP® treatment promises results. As an altered
version of LANAP® – the laser gum disease
treatment – the Laser Assisted Peri-Implantitis
Procedure is designed to preserve implants and
protect the surrounding tissue from further decay.

30. PHOTODYNAMIC THERAPY:
 Photodynamic therapy generates reactive oxygen species by multiplicity
with help of a high-energy single-frequency light (e.g. diode lasers) in
combination with photosensitizers (e.g. toluidine blue).
Wave length range = 580 to 1400 nm , toluidine blue-concentrations =between 10 and 50 ug/ml
 Aggregatibacter actinomycetemcomitans
 Porphyromonas gingivalis
Prevotella intermedia
Streptococcus mutans
Enterococcus faecalis
 Bactericidal against;
Manual treatment by titanium curettes &glycine air powder + adjunctive photodynamic
therapy
Reduction of periopathogenic bacteria & IL-1 BETA
12 MONTHS Basseti et al

31. SURGICAL THERAPY
Non-surgical therapy + Resective/Regenerative therapy
RESECTIVE THERAPY:
Patients with active peri-implant disease surgical pocket elimination and bone re-contouring in
combination with plaque control before and after surgery represents an effective treatment.
- SERINO ET AL
Peri-implantitis with granulation tissue. Peri-implantation 1 week after resective therapy.
 Ostectomy and osteoplasty combined with implantoplasty represent an
effective therapy to reduce or even stop peri-implantitis progression
In a radiographic study with 3 years follow-up,marginal bone loss after resective surgery with
implantoplasty was significantly lower than after resective therapy only.
- ROMEO ET AL

32. Regenerative therapy– defect after degranulation
Regenerative therapy– defect fill with a xenograft material
(BioOss ® , Geistlich, Switzerland)
Membrane application (BioGide ® ,
Geistlich, Switzerland) Preoperative radiograph of the
peri-implant defect.
Postoperative radiograph 12 months
after regenerative therapy
REGENERATIVE APPROACHES:
o The results of studies using a combination of membranes and bone graft materials
were superior to those using membranes or bone grafts alone and tend to give the
best results.
o There is a tendency that xenograft materials in combination with a resorbable
membranes might have advantages in terms of re-osseointegration.

33. conclusion
 No “ideal peri-implantitis therapy” have been described.
 Therefore, prevention is the most important factor.
 Continuous check-up intervals with professional teeth and implant
cleaning is necessary.
 Risk factors such as smoking and active or previous periodontitis.
 In non-surgical therapy, combinations of mechanical cleaning with
curettes and air polishing systems are recommendable.
 Adjuvant antiseptic rinses and local or systemic antibiotics are effective.
 Surgical therapy with resective and augmentative procedures completes
the treatment options.
 Proper awareness must be created by understanding the condition.

34. References
Carranzas-Clinical periodontology (12th edition)
Peri-implant tissue remodelling-by Luigi Canullo,
Roberto Cocehetto, Ignazio Loi
Journal of international clinical dental research
organisation
Journal of inter disciplinary dentistry
Peri-implant tissue-dear doctor (dentistry&oral health)
Head and face medicine (biomed central)
Journal of dental implantology
US national library of medicine