Peri-Implantitis Treatment: What the Evidence Shows

Peri-implantitis is one of the more common long-term problems with dental implants, and it has attracted many of the same devices and add-on treatments that are marketed for gum disease. This article sets out what the research shows about treating it, drawing mainly on the European Federation of Periodontology’s 2023 guideline and the systematic reviews and trials behind it, so that a patient facing treatment knows what is established and what is being sold.

Why It Is Harder to Treat Than Gum Disease

Around a natural tooth, the root is anchored to bone by a ligament with its own blood supply, and the root surface is smooth. An implant has neither. The bone meets the titanium directly, and most modern implants have a deliberately roughened surface that helps bone attach when the implant is placed and gives bacteria a textured place to live once it is exposed. That surface is also threaded, which makes it hard to clean completely with any instrument.

The consequence shows up in the trials. In a randomized trial of 100 patients with severe peri-implantitis, Carcuac and colleagues found one-year surgical success in 79 percent of implants with an unmodified surface and 34 percent of those with a modified, roughened surface. Same trial, same surgical protocol; the surface made a large difference.

The Guideline in Brief

The EFP S3 level clinical practice guideline for the prevention and treatment of peri-implant diseases, published in the Journal of Clinical Periodontology in 2023, was developed with GRADE methodology from thirteen commissioned systematic reviews and a structured consensus of experts and stakeholders. Its recommendations are graded: “we recommend” for strong evidence, “we suggest” for weaker evidence, and “may be considered” where the choice is left open.

For peri-implantitis it recommends, as the first line of treatment, trying to keep an implant that is still acceptable to the patient; starting with a non-surgical step; re-evaluating; and then moving either to surgery or to supportive care depending on the result. It also recommends that dental teams offering implants be able to manage peri-implantitis, and, because the surgery is complex, that it be provided by dentists with specific training or by specialists. The EFP’s summary of the recommendations is public.

Step One: Non-Surgical Treatment

The guideline recommends cleaning above and below the gumline with curettes or sonic and ultrasonic instruments, oral hygiene instruction, risk-factor control, and cleaning, removing or modifying the restoration where it traps plaque, with periodontal treatment of the natural teeth as needed.

The endpoints for this step are residual pockets of 5 mm or less, with no bleeding on probing at more than one site and no suppuration. Implants that meet them go to maintenance; the rest need more treatment.

Many things have been added to the cleaning in trials, and the reviews for the guideline found little to show for most of them:

• Lasers and air polishing. Cosgarea and colleagues reviewed nine randomized trials of lasers, air-abrasive devices and a novel ultrasonic device. Results were inconsistent across trials, no meta-analysis was possible, and the authors concluded that clinical and patient-reported benefits remain to be demonstrated. The guideline does not suggest lasers, alone or added to cleaning, and suggests not using air polishing.
• Antibiotics. Liñares and colleagues found that local antimicrobials placed in the pocket led to modest improvements in pocket depth, and that antibiotic pills produced significantly greater reductions, especially at pockets deeper than 6 mm. The guideline nonetheless does not suggest local antimicrobials and recommends against the routine use of antibiotic pills in this step.
• Photodynamic therapy, desiccant gels and probiotics are not suggested either.

Step Two: Surgery

When the non-surgical endpoints are not met, the guideline recommends surgery, with access flap or resective surgery as the recommended approaches. Opening the gum lets the implant surface be seen and cleaned directly, and resective surgery reshapes the bone and gum so the area can be kept clean afterward.

Surgery works, within limits. A meta-analysis for the guideline by Karlsson and colleagues, pooling 13 prospective cohorts, found pocket depth reduced by about 2.2 mm on average, with deeper starting pockets improving more. It also found that recurrence during follow-up of one to five years was frequent and that implant loss was not uncommon. No studies directly compared surgical with non-surgical treatment.

Bone grafting. The largest trial of reconstructive surgery, a multicenter randomized trial of 138 patients by Derks and colleagues, compared access flap surgery with and without a bone substitute. At twelve months both groups gained about 3.7 mm of pocket reduction and about 1 mm of bone, the bone substitute did not improve pocket depth or bleeding, and the gum receded less on the visible side in the grafted group. Patient satisfaction was high in both. The guideline leaves the choice open and suggests reconstructive procedures preferably for intra-bony defects at least 3 mm deep.

Cleaning the implant surface. In the review by Ramanauskaite and colleagues, the evidence on air polishing, titanium brushes and the Er:YAG laser during surgery was too limited to be conclusive. The laser produced greater pocket reduction at six months in one trial, but no difference at one and two years in another, and did not improve bleeding in either. Titanium brushes may reduce inflammation. The guideline does not suggest air polishing, the Er:YAG laser, chlorhexidine or photodynamic therapy for surface decontamination, allows titanium brushes to be considered, and found insufficient evidence to recommend for or against implantoplasty, the smoothing of exposed threads.

Antibiotics with surgery. In the Carcuac trial, local chlorhexidine had no overall effect. Antibiotic pills made no difference at implants with an unmodified surface and helped at roughened ones, but the authors noted that the likelihood of success with antibiotics at those implants was still low. The guideline recommends against systemic antibiotics as an add-on to surgery, and found insufficient evidence either way on local antibiotics.

What Success Means, and How Often It Happens

The guideline defines successful surgical treatment as no more than one site bleeding on probing, no suppuration, pockets of 5 mm or less, and no further bone loss, with measurements recorded at six months and an X-ray at twelve. That is a demanding standard, and published success rates depend on which version of it a study uses.

• In the Carcuac trial, 45 percent of implants met the success criteria at one year.
• In the Derks trial, pockets and bleeding improved substantially, but only 16.4 percent of grafted and 13.5 percent of non-grafted implants met every criterion, which in that study also required no more than 1 mm of gum recession on the visible side.
• In a five-year cohort by Heitz-Mayfield and colleagues of 24 patients treated surgically and kept in supportive care, 63 percent of patients still had a successful outcome at five years; some had the disease return and some lost an implant.
• In a five-year series of reconstructive treatment by Roccuzzo and colleagues, overall success was 45.3 percent, and patients who did not fully keep their maintenance appointments had more complications and implant loss.

A fair summary for a patient: treatment usually stops the inflammation and deepening of the pockets, a smaller share of implants return to a state that meets every criterion for health, and the results are kept by maintenance, not by the surgery alone.

Maintenance Decides the Long Run

The best evidence for prevention is also the best evidence for keeping a treated implant. In a five-year follow-up by Costa and colleagues of patients who already had inflammation around an implant, peri-implantitis developed in 18 percent of those who kept preventive maintenance and 43.9 percent of those who did not. The guideline recommends a structured supportive care program, with periodic assessment, for every patient with implants. What periodontal maintenance means explains what those visits involve.

Questions to Ask About a Treatment Plan

• What are the pocket depths and how much bone has been lost, compared with the X-ray from when the crown was placed?
• Is the crown or the cement contributing, and will it be corrected first?
• What is the non-surgical step, and when will it be re-evaluated?
• If surgery is proposed, is the plan to reshape the area or to graft it, and why for this defect?
• Is a laser, air polishing or a course of antibiotics part of the plan, and what is it expected to add? The guideline advises against each.
• What is the maintenance schedule afterward?

Austin Periodontal Associates follows this sequence, treats implants placed at any office, and does not use lasers or antimicrobials. Peri-implantitis treatment describes what the visits involve. Request a consult in North Austin, or call (512) 346-6097.