Restorative Dentistry

Enhanced CPD DO C

Vanessa Sousa

Víctor Beltrán, Nikos Mardas, Lochana Nanayakkara and Nikolaos Donos

Treatment of Peri-implantitis:
Fiction or Reality?
Part 1: Non-surgical and
Surgical Management
Abstract: Peri-implantitis is a biological complication characterized by an inflammatory process affecting the soft and hard tissues around
an osseo-integrated load-bearing implant. Clinically, it results in progressive bone loss, pocket formation, bleeding and/or suppuration and
leads to implant loss. Although the main aetiological factor is bacterial biofilms, the clinical presentation and progression of peri-implantitis
is exacerbated by several local, systemic and iatrogenic factors. Treatment protocols of peri-implantitis include various decontamination
procedures of the exposed implant surface. In this two-part series, we will review the available evidence for the non-surgical and surgical
management of peri-implantitis (Part 1), and then we will discuss various modalities for implant surface decontamination (Part 2).
CPD/Clinical Relevance: The pre-operative risk identification and management at both patient and site level, early diagnosis and regular
supportive peri-implant care are fundamental for long term implant success and survival.
Dent Update 2023; 50: 731–738

A classification for peri‐implant health

Vanessa Sousa, DDS, MJDFRCS, CertPerio, MS, MPerioRCS, MA, FHEA, FCGDent, FDSRCS,
and diseases was published in 2018 and
PhD, Clinical Lecturer and Honorary Consultant in Periodontology, Periodontology Unit,
subsequently modified in 2023 (Table 1).1,2
Centre for Host–Microbiome Interactions, Faculty of Dentistry, Oral and Craniofacial
Peri‐implant health is characterized by the
Sciences, King’s College London, Guy’s and St Thomas’ NHS Foundation Trust; Specialist
absence of: erythema; bleeding on probing;
Practitioner, Private Practice, London. Víctor Beltrán, DDS, MS, PhD, Associate Professor
swelling; and/or suppuration. However, it
in Periodontology and Implant Dentistry, Postgraduate Academic Dean, Director of
is not possible to define a range of probing
Clinical Investigation and Dental Innovation Center, Institute of Dentistry, Universidad
depths compatible with health.1
de La Frontera, Temuco, Chile; Specialist Practitioner, Private Practice, Temuco,
Peri‐implant mucositis is mainly
Chile. Nikos Mardas, DiplDS, MS, PhD, Clinical Reader and Honorary Consultant in
characterized by bleeding on gentle
Periodontology, Undergraduate Periodontology Lead, Centre for Immunobiology probing, a decrease in probing resistance,
and Regenerative Medicine, Centre for Oral Clinical Research, Institute of Dentistry, erythema, swelling, and/or suppuration.1
Queen Mary University of London; Specialist Practitioner, Private Practice, London. Peri‐implantitis was defined as a plaque‐
Lochana Nanayakkara, BDS, MJDFRCS, MS, FDSRCS, Consultant in Restorative Dentistry, associated pathological condition occurring
Director of Dental Education, Royal London Hospital, Barts Health NHS Trust; Honorary in tissues around dental implants, which
Senior Lecturer, Co-Lead for DClinDent Programme in Prosthodontics, Institute of Dentistry, is characterized by inflammation and
Queen Mary University of London; Specialist Practitioner, Private Practice, London. progressive loss of supporting bone.1
Nikolaos Donos, DDS, MS, FHEA, FDSRCS, PhD, Professor of Periodontology and Implant Peri‐implantitis sites show clinical signs of
Dentistry, Honorary Consultant in Periodontology, Director of Research, Director of Centre inflammation, bleeding on probing and/or
for Oral Clinical Research, Institute of Dentistry, Queen Mary University of London; Royal suppuration, increased probing depths and/or
London Hospital, Barts Health NHS Trust; Specialist Practitioner, Private Practice, London. recession of the mucosal margin, in addition
email: vanessa.sousa@kcl.ac.uk to radiographic bone loss.1,3

October 2023 DentalUpdate 731

pg731-738 Sousa.indd 731 09/10/2023 15:03

 Restorative Dentistry

Peri-implant health Peri-implant mucositis Peri-implantitis

Absence of clinical signs of soft Signs of inflammation Signs of inflammation
tissue inflammation, and no Line or drop of bleeding within 30 seconds following Increased probing depth compared with
increase in probing pocket depth probing probing depth values collected after
compared to previous examinations placement of the prosthetic reconstruction
No BoP BoP BoP
No bone loss* No bone loss* Bone loss*
Following the ID-COSM initiative Following the ID-COSM initiative consensus,2 this In the absence of baseline and/or previous
consensus international consensus definition has been updated to: presence of bleeding examination records:
report,2 this definition has been (more than one spot at a location around the  BoP ± S
slightly modified and allows for the implant or presence of a line of bleeding or profuse  PPD ≥6 mm
presence of a single bleeding spot bleeding at any location) and/or suppuration on  BL ≥3 mm apical of the most coronal
around the implant gentle probing, in the absence of bone loss beyond portion of the IO part of the implant (IP
crestal bone level changes resulting from initial reference for epidemiological studies)
bone remodelling4
Table 1. Peri-implant diseases and conditions: case definitions in clinical practice.1 *Beyond crestal bone-level changes resulting from initial healing. Baseline
radiograph with supra-structure in place. Changes ≥2 mm at any time point during, or after, the first year of function are regarded as pathological. BoP:
bleeding on probing; S: suppuration; PPD: probing pocket depth; BL: bone levels; ID-COSM: Implant Dentistry Core Outcome Set and Measurements; IO:
intra-osseous; IP: implant platform.

Considerations

Patient-specific Periodontal disease (susceptibility/active/Hx), SPC compliance,
OH self-care, plaque control, smoking, systemic disorders,
genetics, DM, medications, stress, Hx radiotherapy in the
jawbone, craniofacial growth, Hx bruxism
Site-specific Percentage of sites with BoP, prevalence of PPD ≥5 mm,
periodontal BL in relation to age, endodontic infections, loss
of periodontal support, longitudinal root fractures, thin buccal
bone morphotype, gingival tissue thickness, tooth position in
the arch, traumatic XLA, pneumatization of the maxillary sinus
Clinician/procedure DH OH education, motivation,
monitoring of habits and
lifestyle, SPC
Surgeon Professional expertise
Prosthodontist Planning, execution and long-
term follow-up
Implant/prosthesis Implant prosthesis-related factors (design, contours,
restorative margins, fit, excess cement), distance from
restorative margin to the bone
Table 2. Risk factors and other considerations for peri-implant diseases and conditions. Hx: history; OH:
oral hygiene; DM: diabetes mellitus; BoP: bleeding on probing; PPD: probing pocket depth; BL: bone
loss; XLA: extraction; DH: dental hygienist skills and devices; SPT: supportive periodontal care.
The successful management of peri- pocket depth (PPD) of 5 mm with no BoP
implantitis is based on the evaluation of may predict the cessation of bone loss and
composite therapeutic endpoints that the successful outcome of peri-implantitis
correspond to disease resolution. These therapy.6,7 In addition, secondary outcome
include the presence of shallow pockets measures such as inflammatory biomarkers
with no bleeding on probing (BoP) or in peri-implant crevicular fluid (PICF) and
suppuration, and the maintenance of microbiological assessment of subgingival
radiographic bone levels. As clinical signs mucosal plaque samples may be used.
of pathology are more frequent in implants Currently the treatment of peri-
with progressive bone loss,5 a probing implantitis remains a clinical challenge.6
Applied treatment modalities for peri-
implantitis1 have hitherto been based on
the assumption of its aetiological similarity
to periodontitis, and therefore, anti-infective
protocols, which aim mainly at resolving
inflammation and arresting the disease
progression by controlling the subgingival
bacterial biofilm,7 have been adopted for
its treatment. For instance, peri-implant
mucositis, a reversible inflammatory
process of peri-implant soft tissues without
supporting bone loss,1 can be successfully
treated by supra/submucosal mechanical
debridement, in conjunction with the
administration of local antiseptics and
preventive measures to reinforce oral
hygiene.8,9 Although peri-implant mucositis
shares certain similarities with gingivitis,
experimental peri-implant mucositis leads
to a greater increase in bleeding sites
compared with experimental gingivitis, and
may take longer than 3 weeks for clinical
reversibility.10 Peri-implantitis treatment often
consists of a combination of non-surgical,
submucosal instrumentation, followed by
surgical flap procedures to provide access for
debridement and decontamination of the
exposed implant surface and, in some cases,
with the reconstruction of the resulting
osseous defects by means of bone grafting
and barrier membranes.12 The mechanical
disruption of the biofilm in both non-surgical
and surgical approaches has been combined
with the adjunctive use of antibiotics (local/
systemic),13 local chemical agents, laser or air-
powder abrasives.14

732 DentalUpdate October 2023

pg731-738 Sousa.indd 732 09/10/2023 15:03


a
b cleansability
Figure 1. (a) Clinical appearance of an implant
affected by peri-implantitis after raising a
mucoperiosteal flap. Advanced bone resorption
can be observed. Trephine explantation was
performed in order to obtain a small portion
of bone adjacent to the implant. (b) Technical
histology of plastic inclusion (with x40 toluidine
blue staining). Inflammatory invasion (TCF:
fibrous connective tissue) is observed around
a thread of the implant (I) deep in the peri-
implant intra-osseous defect (TO: bone tissue).
Reproduced from Sousa et al.11
A recent consensus statement9 has
indicated that prosthetic overcontouring
(emergence angle >30° combined with a
convex emergence profile of the abutment/
prosthesis) is associated with an increased
risk for peri-implantitis.15 Furthermore, it
appears that reconstructive peri-implantitis
treatment may facilitate the maintenance
of post-operative peri-implant soft-tissue
levels (Table 2).16
Therapeutic strategies for the
management of peri-implant diseases
have been described in the literature.17,18
Historically, literature has delineated
a cumulative interceptive supportive
therapy protocol17 for the prevention and
management of peri-implant diseases.
Recently, the European Federation
of Periodontology (EFP) has recently
October 2023
pg731-738 Sousa.indd 733
Restorative Dentistry
Peri-implant Endpoints Recommendations for clinicians4
condition (at implant
(treatment phase) level)
Peri-implant ≤1 point of BoP Evaluate these endpoints 2–3 months after the
mucositis and absence intervention, and in presence of ≥2 BoP sites,
treatment of S or ≥1 sites with profuse BoP, or presence of
suppuration, re-treatment should be rendered
Repeat PMPR if the endpoints of therapy have
not achieved within 3 months after PMPR.
Modify endpoints/evaluation times based on
patient's OH, risk factor profile, and prosthesis
Peri-implantitis Residual Evaluate outcome after 6–12 weeks. Monitor
(non-surgical probing depths cases frequently during healing. If goals are not
step) ≤5 mm with achieved: consider additional treatment
no BoP at
Note: Peri-implantitis therapy starts with a non-
more than one
surgical step, followed by re-evaluation and,
point and no
depending on the outcomes, progress to the
suppuration
surgical step or to SPIC
Peri-implantitis ≤1 point of Record clinical parameters 6 months post-
(surgical BoP, absence treatment. Obtain radiographs at 12 months.
treatment) of S, PPD ≤5 Include complication-free survival of the implant
mm, absence and prosthesis and patient satisfaction in long-
of progressive term evaluation
bone loss
Note: If non-surgical therapy endpoints (PPD
compared to
≤5 mm and ≤1 point of BoP) are not achieved:
pre-treatment
perform surgical therapy
Dental teams providing implant therapy should have the professional expertise
to manage peri-implantitis. Given the complexity of surgical treatment for peri-
implantitis, it is advisable for it to be conducted by dentists with specialized
training or by qualified specialists4
Table 3. Summary of recommended endpoints and evaluation strategies for the treatment of peri-
implant mucositis and peri-implantitis. BoP: bleeding on probing; PMPR: professional mechanical
plaque removal; OH: oral hygiene; S: suppuration; PPD: probing pocket depth; SPIC: supportive peri-
implant care.
introduced the S3 level clinical practice reconstruction of osseous defect with
guideline for the prevention and treatment a bone graft substitute with or without
of peri-implant diseases, which outlines a membrane.
specific therapeutic guidelines and  Post-operative anti-infective control,
establishes objectives for treatment e.g. chlorhexidine rinses as adjuncts to
(Table 3).4 routine oral hygiene practices.
For example, systematic reviews7,19 have  Maintenance care on a regular basis.
suggested a four-phase treatment strategy
Finally, when faced with the clinical
for peri-implantitis:
challenge of the failure of a surgical or
 Pre-treatment phase to include regenerative treatment (Figure 1) or with
oral hygiene and risk management,
cases of severe bone loss coupled with
prosthesis assessment, adjustment
possible complications, such as unfavourable
and removal if required, and non-
implant position or prosthetic failures, then
surgical debridement with or
explantation is recommended.20–22
without antimicrobials.
 If resolution is not achieved, surgical Given the complexity of peri-implantitis
access is indicated by means of a treatment, it is fundamental to:
mucoperiosteal flap for implant surface  Perform a risk estimation and
decontamination and modification or management at patient and site level;23
DentalUpdate 733
09/10/2023 15:03
 Restorative Dentistry

Update to inform patients of their individual risk

profile during the consent process. The
Medical, social, dental, history, risk assessment and presenting complaints Implant Disease Risk Assessment (IDRA)
is a risk stratification tool that helps to
Access and record estimate the risk of a patient developing
peri-implantitis.23 Therefore, the decision
Full mouth plaque and bleeding scores, probing pocket depths, presence of calculus whether implant treatment should
and/or cement, bleeding and/or suppuration, recession, presence of wear facets, be performed should be based on an
prosthetic supra-structure, light occlusion, contacts, percussion, mobility (implant and/or assessment of the patient’s risk profile at
prosthesis), behaviour, lifestyle the patient level, as well as at the site level
(Figure 2).25
Compare
Clinical and radiographic records (baseline, previous appointment and current) Non-surgical treatment
of peri-implantitis
Motivate and reinforce Non-surgical mechanical plaque control
could be effective in the treatment of peri-
Primordial, primary, secondary, and tertiary prevention. Promotion of health and
implant mucositis through the reduction
protection from risk, procedures to identify and eliminate early stage of disease and
of bacterial load and inflammation
address the damage caused by disease and to maintain or improve residual function
within peri-implant soft tissues. In peri-
implantitis therapy, non-surgical treatment
Instrumentation protocols are considered the first step of
management, which also serves to optimise
Evidence-based following EFP S3 level clinical practice guidelines, and depending on patient’s oral hygiene, risk factor profile
clinical need4 and marginal tissues for the next phase of
treatment.26 However, various instruments
and approaches, aimed at removing both
Recall intervals
supra- and subgingival biofilm, such as
Based on specific risk factors (patient, systemic, local, implant, prosthesis), ranging from plastic, carbon or titanium curettes, sonic
3 up to 6 months. The higher the risk, the shorter the recall. Post non-surgical treatment or ultrasonic scalers, rubber polishers, and
of peri-implantitis, it is proposed that SPIC be administered every 3–4 months during the air-powder flows, have been proven to be
initial 12 months, beginning at 3 months post-treatment. Following surgical intervention insufficient to ensure complete removal
for peri-implantitis, it is advised that SPIC be administered every 3–4 months during the of bacteria on implant surfaces, and have
first 12 months, beginning at 3 months post-surgery4 only a moderate short-term effect on the
Figure 2. Framework for supportive periodontal and peri-implant care in patients with dental improvement of clinical parameters (such
implants. SPIC: supportive peri-implant care. as a reduction in PPD),9,27,28 radiographic
or microbiological outcomes (Figure 3).9
a b
In addition, the effect of the cleaning
methods on different implant surfaces,
such as the use of plastic scalers, titanium
brushes and air-abrasive systems, may lead
to surface topography modifications on
rough and smooth titanium implants.
Despite evidence that some specific
surface decontamination protocols may
be effective in reducing bacterial load,
Figure 3. Scanning electron microscopy images showing (a) microcosm biofilms grown on top of clinical pocket depths and peri-implant
machined titanium discs (scale bar: 5 µm, magnification ×5000), and (b) machined titanium surfaces mucosal inflammation, non-surgical
following decontamination employing titanium brushes (scale bar: 2 µm, magnification ×10,000). treatment of peri-implantitis has often
Reproduced from Sousa et al.30 been reported as insufficient for disease
resolution. Moreover, one study reported
that 11% of patients had at least one
implant removed during surgical treatment
 Discuss relevant information on the  Highlight the importance of regular
of peri-implantitis or at some time point
periodontal status of the remaining and thorough maintenance (supportive after surgery because peri-implantitis had
dentition and patient-reported periodontal and peri-implant care). reached its terminal stage, and implant
outcomes with patients;24 The above reinforces the need loss was unavoidable.29 Notably, no single
 Highlight the importance of prevention, for clinicians to identify and optimise method of non–surgical implant surface
early diagnosis and early management modifiable risk factors prior to implant instrumentation decontamination has been
of peri-implant mucositis; placement, and to use this information found to be superior.30 Part 2 of this series

734 DentalUpdate October 2023

pg731-738 Sousa.indd 734 09/10/2023 15:03


discusses in detail the evidence in relation to
adjuvant antimicrobial and decontamination
modalities following non-surgical and/or
surgical treatment of peri-implantitis.
In order to potentiate the effectiveness of
mechanical plaque control, several clinicians
have suggested the adjunctive use of other
antimicrobial therapeutics or approaches.
Currently, there is limited evidence regarding
the use of systemic antimicrobial protocols
as adjuncts to mechanical therapy, which
hinders robust conclusions regarding
their effectiveness considering possible
side effects (e.g. antibiotic resistance) and
increased cost (e.g. laser equipment).31
Larger randomized controlled clinical trials
are still required to assess their effect on
clinical outcomes. Specifically, FGDP (UK) and
European Federation of Periodontology (EFP)
S3 level clinical practice guidelines do not
recommend systemic or local antimicrobials
for peri-implant mucositis. However, local
measures to improve self-care oral hygiene
are strongly recommended. Similarly,
FGDP (UK) does not recommend the use
of antimicrobials as an adjunct to local
management of peri-implantitis.4,32
Surgical treatment
of peri‑implantitis
Current surgical treatments for peri-
implantitis, such as access flap,
reconstructive, resective, and combination
approaches, include the removal of the peri-
implant inflammatory granulation tissue and
the decontamination of the exposed implant
surface.3,12,33,34 According to the current EFP
S3 level clinical practice guideline for the
prevention and treatment of peri-implant
diseases,4 there is insufficient evidence to
recommend the use of implantoplasty.
However, the use of implantoplasty has been
considered in specific cases, in conjunction
with regenerative or resective surgery. 35–37
The modification of the implant surface
by implantoplasty (Figure 4), along with
a resective surgical approach (performed
on supracrestal/horizontal, infrabony and
some combined defects), has also been
proposed as an effective treatment for
peri-implantitis.39 Clinical improvements
following the surgical treatment of peri-
implantitis are usually measured against
clinical parameters, such as reduction of
PPDs, absence of BoP and radiographic bone
fill of bony defects indicating long-term
stability.3,38,39 However, 2 years after therapy,
50% of patients continued to exhibit signs of
peri-implantitis.29,40 Notwithstanding, careful
October 2023
pg731-738 Sousa.indd 735
Restorative Dentistry
consideration should be given to this surgical a
approach, as implantoplasty procedures can
lead to implant mechanical complications
(implant fracture), and to the release of
nanometre-sized particles that can trigger
local-level reactions, and the full systemic
effect is not fully understood at present.37,41
As previously described for non-surgical
treatment of peri-implantitis, many implant
surface decontamination procedures
have been suggested as part of surgical
treatment, through the use of carbon or
plastic curettes, ultrasonic scalers, titanium b
brushes, air-polishing devices using
sodium bicarbonate or glycine powder,
irradiation with hand or soft laser light,
photodynamic therapy or the application
of acids or various antimicrobial agents.18,42
While these studies report on the efficacy
of these procedures, the role of implant
surface characteristics may also influence
treatment outcomes.43
One study evaluated the effect of
surgical treatment of peri-implantitis in Figure 4. (a) Surgical access and (b) debridement
a preclinical setting, using different anti- using diamond piezosurgical tips on a maxillary
infective procedures, such as surgical implant (UL1) affected by peri-implantitis.
debridement of the implant sites, in Reproduced from Sousa et al.11
conjunction with either normal saline or
0.2% chlorhexidine, comparing different
implant surfaces.44 It was shown that:
 The local use of chlorhexidine has minor Regenerative procedures
effects on treatment outcomes; A meta-analysis of treatment outcomes12
 Resolution of peri-implantitis was identified the main surgical procedures that
possible without the use of adjunctive are predominantly performed in the surgical
local and systemic antibiotics; access phase:
 The results were influenced by implant
 Access flap debridement;
surface characteristics.
 Surgical resection;
A randomized controlled clinical trial  Regeneration with bone grafts;
has suggested that treatment outcomes  Guided tissue regeneration.
for implants with a modified surface had
The outcomes of regenerative therapy
significantly lower odds for treatment
are reported to be the most variable.12 It
success.13 They mentioned that the use of
adjunctive systemic antibiotics, such as oral is important to emphasize that, overall,
amoxicillin 750 mg twice daily for 10 days, peri-implantitis lesions do not respond
was likely to yield positive effects in patients predictably to either non-surgical or
with implants with modified surfaces.13 surgical treatments.
However, more recently, this study reported In terms of regenerative therapy,
3-year follow-up results that indicated that autogenous bone, allogenic decalcified
the potential benefits of systemic antibiotics freeze-dried bone, xenogenic de-proteinized
are not sustained over this period, although bone mineral, phytogenic calcium carbonate,
the surgical treatments were still deemed to hydroxyapatite or tri-calcium phosphate
be effective.13 and porous titanium granules (PTGs),47 with
Further studies are needed to clarify the or without employing e-PTFE, collagen
effect of implant surface characteristics on or resorbable synthetic membranes, have
treatment outcomes45 and the influence of been used in an attempt to reconstruct peri-
adjunctive use of antibiotics on treatment implant defects and attain bone regeneration.
outcome is still unknown. Furthermore, A meta-analysis demonstrated higher
adequately powered randomized controlled reduction in PPDs and BoP when using bone
trials in this area of research are of grafts and barrier membranes, in comparison
high priority.46 to employing grafts alone.12 However, as
DentalUpdate 735
09/10/2023 15:03
 Restorative Dentistry
reported in a recent systematic review and
meta-analysis, it is important to highlight that
there is lack of evidence suggesting improved
aesthetic or patient-reported outcomes
following reconstructive therapy at peri-
implantitis-related bone defects.40
A recent randomized multicentre
trial demonstrated the benefits of bone
grafting in combination with an open
flap debridement (OFD) procedure for the
treatment of advanced peri-implant osseous
defects compared with OFD alone.47 Both
surgical treatment approaches included
the use of a titanium brush for implant
surface decontamination and adjunctive
systemic antibiotics. Although no significant
differences were observed regarding BoP
and PPD reduction between the groups,
the radiographic bone fill was superior
in the group including the bone grafts.
The challenge of achieving a successful
regenerative therapy in peri-implantitis
will greatly depend also on the patient’s
systemic conditions and the morphological
configuration of the peri-implant bone
defect, in relation to the number of bone
walls that determine its configuration.3,13,34,48
Furthermore, it has been reported that good
oral hygiene plays a pivotal role in long-term
stability (4-year follow up) after regenerative
treatment of peri-implantitis (combining
a xenograft and a collagen membrane).49
Regardless of the chosen surgical method
and biomaterial use, attaining resolution
of peri-implantitis remains challenging.
Over the long term, several implants might
experience disease recurrence, requiring
further surgical interventions or potentially
resulting in implant loss.50
Re-osseo-integration
The ultimate goal of surgical regenerative
treatment of peri-implantitis should be
re-osseo-integration: the growth of new
bone in direct contact with the previously
contaminated implant surface.50,51 Therefore,
regenerative surgical treatment should aim to:
 Ensure substantial regeneration of bone
from the walls of the defect;
 Decontaminate the implant surface to
facilitate re-osseo-integration.51
Pre-clinical studies have reported that
re-osseo-integration can be achieved in
previously infected titanium surfaces.52
In two studies investigating the direct
influence of surface decontamination on
re-osseo-integration, it was demonstrated at
a histological level following re-implantation
of previously plaque-infected and
736 DentalUpdate
pg731-738 Sousa.indd 736
decontaminated dental implants into
freshly prepared osteotomies in dogs.52
Similar results were reported in another
preclinical study where electrolytic cleaning
of previously infected implant surfaces
promoted their re-osseo-integration in
fresh osteotomies.53 However, there was
considerable variability within and between
studies, where histological evidence of
re-osseo-integration was unpredictable, and
may not have been achieved for the entire
(previously) contaminated implant surface.12
Re-osseo-integration might be
influenced by a number of factors,
including the implant material, design and
surface characteristics, exhibited bacterial
communities and host state, surgical site
and technique, loading conditions and
time.54 As such, direct comparison of bone-
to-implant contact figures between studies
can be difficult.
Following the treatment of peri-
implantitis by employing a regenerative
approach, large variations in the amounts
of re-osseo-integration, from 1% to
84% have been reported.55 The implant
surface characteristics could be one of the
factors responsible for this variability.56
It is well known that bacterial adherence
is enhanced by the micro-irregularities
of implant surfaces, and as long as
contamination is present, wound healing
will be variably compromised.55
Conclusions
It is advised to adhere to the EFP S3
level clinical practice guidelines for peri-
implant disease prevention and treatment,
implementing a standardized protocol for
peri-implantitis management. The following
factors merit consideration:
 Patients’ risk profile at an individual
and site level should be evaluated prior
to the commencement of a treatment
plan, with specific attention to medical
and lifestyle risk factors for peri-implant
and periodontal diseases.
 Non-surgical implant surface
instrumentation with or without
adjunctive chemotherapeutics, or other
antimicrobial strategies, has a moderate,
short-to-mid-term improvement in
clinical parameters.
 In the surgical treatment of osseous
defects among peri-implantitis patients,
considering an access flap with or
without reconstructive measures
is viable. To date, no evidence has
established the superiority of any
particular reconstructive surgical
approach. The routine use of adjunctive
antibiotics in the surgical treatment of
peri-implantitis is not recommended
by current guidelines. Given the
complexity of surgical treatment for
peri-implantitis, it is recommended
for it to be conducted by dentists with
specific training or by specialists.
 Reconstruction of peri-implant bone
defects with new bone formation and
re-osseo-integration has been reported
with various degrees of success,
which may be influenced by various
factors including defect morphology,
material selection and implant
surface characteristics. Furthermore, it
has been suggested that reconstructive
procedures should be preferably be
applied at intra-osseous defects with a
depth of ≥3 mm.
A substantial knowledge gap persists
regarding the optimal implant surface
decontamination protocol. To date, none of
the clinically described methodologies has
demonstrated total biofilm elimination.
Further research is required in the
development of biomaterials with
antibacterial potential and osteo-
inductive properties that can be used in
the context of regenerative treatment
of peri‑implantitis.
Acknowledgements
The authors thank everyone who has
provided their time and input in the
development of these articles, in particular
to Dr A Yogarajah, for his feedback on
both manuscripts.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
VS was supported by the NIHR (CL).
VB and VS were supported by Project
REDI170658, ANID.
References
1. Berglundh T, Armitage G, Araujo MG et al. Peri-
implant diseases and conditions: consensus report
of workgroup 4 of the 2017 World Workshop on
the Classification of Periodontal and Peri-Implant
Diseases and Conditions. J Clin Periodontol 2018;
45 Suppl 20: S286–291. https://doi.org/10.1111/
jcpe.12957
2. Tonetti MS, Sanz M, Avila-Ortiz G et al. Relevant
domains, core outcome sets and measurements
for implant dentistry clinical trials: The Implant
Dentistry Core Outcome Set and Measurement
(ID-COSM) international consensus report. J Clin
Periodontol 2023; 50 Suppl 25: 5–21. https://doi.
October 2023
09/10/2023 15:03
 Restorative Dentistry

October 2023 DentalUpdate 737

pg731-738 Sousa.indd 737 09/10/2023 15:03

 Restorative Dentistry
org/10.1111/jcpe.13808
3. Schwarz F, Alcoforado G, Guerrero A et al. Peri-
implantitis: summary and consensus statements of
group 3. The 6th EAO Consensus Conference 2021.
Clin Oral Implants Res 2021; 32 Suppl 21: 245–253.
https://doi.org/10.1111/clr.13827
4. Herrera D, Berglundh T, Schwarz F et al; EFP workshop
participants and methodological consultant.
Prevention and treatment of peri-implant diseases
– the EFP S3 level clinical practice guideline. J Clin
Periodontol 2023; 50 Suppl 26: 4–76. https://doi.
org/10.1111/jcpe.13823
5. Fransson C, Lekholm U, Jemt T, Berglundh T.
Prevalence of subjects with progressive bone loss at
implants. Clin Oral Implants Res 2005; 16: 440–446.
https://doi.org/10.1111/j.1600-0501.2005.01137.x
6. Klinge B, Meyle J. Peri-implant tissue destruction.
The Third EAO Consensus Conference 2012. Clin Oral
Implants Res 2012; 23 Suppl 6: 108–110. https://doi.
org/10.1111/j.1600-0501.2012.02555.x
7. Heitz-Mayfield LJA, Mombelli A. The therapy of peri-
implantitis: a systematic review. Int J Oral Maxillofac
Implants 2014; 29 Suppl:3 25–45. https://doi.
org/10.11607/jomi.2014suppl.g5.3
8. Dommisch H, Hoedke D, Valles C et al. Efficacy
of professionally administered chemical agents
as an adjunctive treatment to sub-marginal
instrumentation during the therapy of peri-implant
mucositis. J Clin Periodontol 2023; 50 Suppl 26: 146–
160. https://doi.org/10.1111/jcpe.13747
9. Renvert S, Roos-Jansåker A-M, Claffey N. Non-
surgical treatment of peri-implant mucositis and
peri-implantitis: a literature review. J Clin Periodontol
2008; 35: 305–315. https://doi.org/10.1111/j.1600-
051X.2008.01276.x
10. Heitz-Mayfield LJA, Salvi GE. Peri-implant mucositis. J
Periodontol 2018; 89 Suppl 1: S257–266. https://doi.
org/10.1002/JPER.16-0488
11. Sousa V, Beltrán V, Janicki T. Understanding peri-
implantitis: inception, treatment, long-term
management, and future directions. 2023. Available
at: https://osf.io.
12. Chan H-L, Lin G-H, Suarez F et al. Surgical
management of peri-implantitis: a systematic
review and meta-analysis of treatment outcomes.
J Periodontol 2014; 85: 1027–1041. https://doi.
org/10.1902/jop.2013.130563
13. Carcuac O, Derks J, Abrahamsson I et al. Surgical
treatment of peri-implantitis: 3-year results from a
randomized controlled clinical trial. J Clin Periodontol
2017; 44: 1294–1303. https://doi.org/10.1111/
jcpe.12813
14. Leonhardt A, Dahlén G, Renvert S. Five-year clinical,
microbiological, and radiological outcome following
treatment of peri-implantitis in man. J Periodontol
2003;174: 1415–1422. https://doi.org/10.1902/
jop.2003.74.10.1415
15. Mattheos N, Janda M, Acharya A et al. Impact of
design elements of the implant supracrestal complex
(ISC) on the risk of peri-implant mucositis and peri-
implantitis: a critical review. Clin Oral Implants Res
2021; 32 Suppl 21: 181–202. https://doi.org/10.1111/
clr.13823
16. Sanz-Martín I, Cha J-K, Sanz-Sánchez I et al. Changes
in peri-implant soft tissue levels following surgical
treatment of peri-implantitis: A systematic review and
meta-analysis. Clin Oral Implants Res 2021; 32 Suppl
21: 230–244. https://doi.org/10.1111/clr.13840
17. Lang NP, Wilson TG, Corbet EF. Biological
complications with dental implants: their prevention,
diagnosis and treatment. Clin Oral Implants Res 2000;
11 Suppl 1: 146–155. https://doi.org/10.1034/j.1600-
0501.2000.011s1146.x
18. Mombelli A, Lang NP. The diagnosis and treatment of
peri-implantitis. Periodontoly 2000 1998; 17: 63–76.
https://doi.org/10.1111/j.1600-0757.1998.tb00124.x
19. Heitz-Mayfield LJ, Aaboe M, Araujo M et al. Group 4 ITI
Consensus Report: risks and biologic complications
associated with implant dentistry. Clin Oral Implants
Res 2018; 29 Suppl 16: 351–358. https://doi.
org/10.1111/clr.13307
20. Sinjab K, Garaicoa-Pazmino C, Wang H-L. Decision
making for management of periimplant diseases.
Implant Dent 2018; 27: 276–281. https://doi.
org/10.1097/ID.0000000000000775
21. de Avila ED, van Oirschot BA, van den Beucken
738 DentalUpdate
pg731-738 Sousa.indd 738
JJJP. Biomaterial-based possibilities for managing
peri-implantitis. J Periodontal Res 2020; 55: 165–173.
https://doi.org/10.1111/jre.12707
22. Sailer I, Karasan D, Todorovic A et al. Prosthetic failures
in dental implant therapy. Periodontol 2000 2022; 88:
130–144. https://doi.org/10.1111/prd.12416
23. Heitz-Mayfield LJA, Heitz F, Lang NP. Implant Disease
Risk Assessment IDRA – a tool for preventing peri-
implant disease. Clin Oral Implants Res 2020; 31:
397–403. https://doi.org/10.1111/clr.13585
24. Sousa V, Mardas N, Farias B et al. A systematic review
of implant outcomes in treated periodontitis patients.
Clin Oral Implants Res 2016; 27: 787–844. https://doi.
org/10.1111/clr.12684
25. Donos N, Laurell L, Mardas N. Hierarchical decisions
on teeth vs. implants in the periodontitis-susceptible
patient: the modern dilemma. Periodontology 2000
2012; 59: 89–110. https://doi.org/10.1111/j.1600-
0757.2011.00433.x
26. Karring ES, Stavropoulos A, Ellegaard B, Karring T.
Treatment of peri-implantitis by the Vector system.
Clin Oral Implants Res 2005; 16: 288–293. https://doi.
org/10.1111/j.1600-0501.2005.01141.x
27. Schwarz F, Nuesry E, Bieling K et al. Influence of an
erbium, chromium-doped yttrium, scandium, gallium,
and garnet (Er,Cr:YSGG) laser on the reestablishment
of the biocompatibility of contaminated titanium
implant surfaces. J Periodontol 2006; 77: 1820–1827.
https://doi.org/10.1902/jop.2006.050456
28. Sordi MB, Perrotti V, Iaculli F et al. Multivariate analysis
of the influence of peri-implant clinical parameters
and local factors on radiographic bone loss in the
posterior maxilla: a retrospective study on 277 dental
implants. Clin Oral Investig 2021; 25: 3441–51. https://
doi.org/10.1007/s00784-020-03666-x
29. Charalampakis G, Rabe P, Leonhardt Å, Dahlén G.
A follow‐up study of peri‐implantitis cases after
treatment. J Clin Periodont 2011; 38: 864–871. https://
doi.org/10.1111/j.1600-051X.2011.01759.x
30. Sousa V, Mardas N, Spratt D et al. The effect of
microcosm biofilm decontamination on surface
topography, chemistry, and biocompatibility
dynamics of implant titanium surfaces. Int J Mol
Sci 2022; 23: 10033. https://doi.org/10.3390/
ijms231710033
31. Klinge B, Gustafsson A, Berglundh T. A systematic
review of the effect of anti-infective therapy in the
treatment of peri-implantitis. J Clin Periodontol 2002;
29 Suppl 3: 213–225. https://doi.org/10.1034/j.1600-
051x.29.s3.13.x
32. Palmer N. Antimicrobial Prescribing in Dentistry: Good
Practice Guidelines. 3rd edn. London, UK: Faculty of
General Dental Practice (UK) and Faculty of Dental
Surgery; 2020.
33. Jepsen S, Schwarz F, Cordaro L et al. Regeneration of
alveolar ridge defects. Consensus report of group 4 of
the 15th European Workshop on Periodontology on
Bone Regeneration. J Clin Periodontol 2019; 46 Suppl
21: 277–286. https://doi.org/10.1111/jcpe.13121
34. Khoury F, Keeve PL, Ramanauskaite A et al. Surgical
treatment of peri-implantitis – Consensus report of
working group 4. Int Dent J 2019; 69 Suppl 2: 18–22.
https://doi.org/10.1111/idj.12505
35. Renvert S, Polyzois I. Treatment of pathologic peri-
implant pockets. Periodontoly 2000 2018; 76: 180–190.
https://doi.org/10.1111/prd.12149
36. Ramel CF, Lüssi A, Özcan M et al. Surface roughness of
dental implants and treatment time using six different
implantoplasty procedures. Clin Oral Implants Res
2016; 27: 776–781. https://doi.org/10.1111/clr.12682
37. Stavropoulos A, Bertl K, Eren S, Gotfredsen K.
Mechanical and biological complications after
implantoplasty – a systematic review. Clin Oral
Implants Res 2019; 30: 833–848. https://doi.
org/10.1111/clr.13499
38. Fransson C, Wennström J, Tomasi C, Berglundh
T. Extent of peri-implantitis-associated bone loss.
J Clin Periodontol 2009; 36: 357–363. https://doi.
org/10.1111/j.1600-051X.2009.01375.x
39. Monje A, Pons R, Amerio E et al. Resolution of peri-
implantitis by means of implantoplasty as adjunct to
surgical therapy: a retrospective study. J Periodontol
2022; 93: 110–122. https://doi.org/10.1002/JPER.21-
0103
40. Tomasi C, Regidor E, Ortiz-Vigón A, Derks J. Efficacy
of reconstructive surgical therapy at peri-implantitis-
related bone defects. A systematic review and
meta-analysis. J Clin Periodontol 2019; 46 Suppl 21:
340–356. https://doi.org/10.1111/jcpe.13070
41. Barrak FN, Li S, Muntane AM, Jones JR. Particle release
from implantoplasty of dental implants and impact
on cells. Int J Implant Dent 2020; 6: 50. https://doi.
org/10.1186/s40729-020-00247-1
42. Hürzeler MB, Quiñones CR, Schüpback P et al.
Treatment of peri-implantitis using guided
bone regeneration and bone grafts, alone or in
combination, in beagle dogs. Part 2: Histologic
findings. Int J Oral Maxillofac Implants 1997; 12:
168–175.
43. Albouy J-P, Abrahamsson I, Persson LG, Berglundh T.
Implant surface characteristics influence the outcome
of treatment of peri-implantitis: an experimental
study in dogs. J Clin Periodontol 2011; 38: 58–64.
https://doi.org/10.1111/j.1600-051X.2010.01631.x
44. Carcuac O, Abrahamsson I, Charalampakis
G, Berglundh T. The effect of the local use of
chlorhexidine in surgical treatment of experimental
peri-implantitis in dogs. J Clin Periodontol 2015; 42:
196–203. https://doi.org/10.1111/jcpe.12332
45. Renvert S, Polyzois I, Claffey N. How do implant
surface characteristics influence peri-implant disease?
J Clin Periodontol 2011; 38 Suppl 11: 214–222. https://
doi.org/10.1111/j.1600-051X.2010.01661.x
46. Berglundh T, Giannobile WV. Investigational
clinical research in implant dentistry: beyond
observational and descriptive studies. J
Dent Res 2013; 92: 107S–108S. https://doi.
org/10.1177/0022034513510531
47. Jepsen K, Jepsen S, Laine ML et al. Reconstruction
of peri-implant osseous defects: a multicenter
randomized trial. J Dent Res 2016; 95: 58–66. https://
doi.org/10.1177/0022034515610056
48. Roccuzzo A, Stähli A, Monje A et al. Peri-implantitis:
a clinical update on prevalence and surgical
treatment outcomes. J Clin Med 2021; 10. https://doi.
org/10.3390/jcm10051107
49. Schwarz F, Wieland M, Schwartz Z et al. Potential
of chemically modified hydrophilic surface
characteristics to support tissue integration of
titanium dental implants. J Biomed Mater Res B Appl
Biomater 2009; 88: 544–557. https://doi.org/10.1002/
jbm.b.31233
50. Donos N, Calciolari E, Ghuman M et al. The efficacy of
bone reconstructive therapies in the management
of peri-implantitis. A systematic review and meta-
analysis. J Clin Periodontol 2023; 50 Suppl 26: 285–
316. https://doi.org/10.1111/jcpe.13775
51. Schou S, Holmstrup P, Skovgaard LT et al. Autogenous
bone graft and ePTFE membrane in the treatment
of peri-implantitis. II. Stereologic and histologic
observations in cynomolgus monkeys. Clin Oral
Implants Res 2003; 14: 404–411. https://doi.
org/10.1034/j.1600-0501.2003.120910.x
52. Alhag M, Renvert S, Polyzois I, Claffey N. Re-osseo-
integration on rough implant surfaces previously
coated with bacterial biofilm: an experimental study
in the dog. Clin Oral Implants Res 2008; 19: 182–187.
https://doi.org/10.1111/j.1600-0501.2007.01429.x
53. Schlee M, Naili L, Rathe F et al. Is complete
re-osseo-integration of an infected dental implant
possible? Histologic results of a dog study: a short
communication. J Clin Med 2020; 9. https://doi.
org/10.3390/jcm9010235
54. Stavropoulos A, Bertl K, Winning L, Polyzois I. What is
the influence of implant surface characteristics and/
or implant material on the incidence and progression
of peri-implantitis? A systematic literature review. Clin
Oral Implants Res 2021; 32 Suppl 21: 203–29. https://
doi.org/10.1111/clr.13859
55. Renvert S, Polyzois I, Maguire R. Re-osseo-integration
on previously contaminated surfaces: a systematic
review. Clin Oral Implants Res 2009; 20 Suppl 4: 216–
227. https://doi.org/10.1111/j.1600-0501.2009.01786.x
56. Persson LG, Ericsson I, Berglundh T, Lindhe J. Guided
bone regeneration in the treatment of periimplantitis.
Clin Oral Implants Res 1996; 7: 366–372. https://doi.org
/10.1034/j.1600-0501.1996.070410
October 2023
09/10/2023 15:03