Peri-implantitis

Peri-implantitis: what causes it, how to prevent it, and what to do when it happens

The complication nobody wants — and everybody eventually sees

Ask any implantologist what keeps them up at night and peri-implantitis is somewhere on the list.

It's the most common serious complication in implant dentistry. It's underdiagnosed, undertreated, and — most importantly — largely preventable. Understanding it isn't optional. It's part of the job.

What peri-implantitis actually is

Peri-implantitis is an inflammatory condition affecting the tissues around an osseointegrated implant. It involves both soft tissue inflammation — peri-implant mucositis — and progressive loss of the supporting bone around the implant.

The distinction matters:

Peri-implant mucositis is reversible. Inflammation of the soft tissue without bone loss. Catch it here and you can resolve it.

Peri-implantitis involves bone loss. It is not reversible in the same way. You can arrest it. You can treat it. But the bone you've lost doesn't simply grow back.

This is why early diagnosis is everything.

What causes it

The primary driver is bacterial biofilm — the same mechanism as periodontitis around natural teeth, but with important differences.

Implants lack a periodontal ligament. They have no mobile attachment apparatus to buffer forces or slow bacterial invasion. The implant-tissue interface is inherently more vulnerable than the tooth-tissue interface. Once bacteria establish themselves subgingivally around an implant, the inflammatory response can progress faster and more aggressively than around a natural tooth.

Contributing factors include:

Poor oral hygiene. The single biggest modifiable risk factor. Non-negotiable patient selection and maintenance.

History of periodontitis. Patients who have had periodontitis are at significantly higher risk of peri-implantitis. Treat the periodontitis first. Stabilise. Then implant.

Smoking. Impairs healing, compromises the immune response, accelerates bone loss. Factor it into your risk assessment at every stage.

Excess cement. Subgingival cement remnants after cemented restorations are a direct cause of peri-implant inflammation. Use screw-retained restorations wherever possible. When you cement, be meticulous about removal.

Implant position and prosthetic design. An implant that's difficult to clean — poorly positioned, with a restoration that doesn't allow proper access — is a maintenance problem waiting to happen. Design for cleansability from the start.

Thin soft tissue. Inadequate soft tissue thickness around an implant is an underappreciated risk factor. Thin biotype tissue provides a weaker biological seal at the implant-tissue interface, offering less resistance to bacterial invasion and less buffer against recession. This brings the surgical decision full circle — placing the implant slightly deeper to encourage tissue thickening, or augmenting soft tissue at placement, isn't just an aesthetic consideration. It's a biological one. The tissue you build at surgery is your first line of defence against peri-implantitis.

Prevention — the only strategy that actually works

Peri-implantitis is easier to prevent than to treat. That's not a cliché — it's a clinical reality.

Patient selection. Don't place implants in patients with uncontrolled periodontitis, poor oral hygiene, or habits they're unwilling to change. The best peri-implantitis treatment is the one you never have to perform.

Soft tissue management at placement. Adequate keratinised mucosa, sufficient tissue thickness, and a well-designed flap are not cosmetic considerations — they are biological ones. The tissue environment you create at surgery determines the long-term stability of the peri-implant seal.

Prosthetic design. Screw-retained where possible. Emergence profiles that allow cleaning. Margins that don't hide cement. Every prosthetic decision either makes maintenance easier or harder.

Maintenance protocol. Every implant patient needs a structured recall programme. Not just a general hygiene appointment — a dedicated implant-focused check. Probing depths, bleeding on probing, radiographic comparison over time. Document everything.

Early detection. Mucositis is your opportunity. Bleeding on probing around an implant is not normal. It's a warning. Treat it aggressively at this stage and you prevent the progression to bone loss.

When it happens — what to do

Despite best efforts, peri-implantitis occurs. Here's the honest framework:

Step 1 — Establish the diagnosis. Probing, bleeding, suppuration, radiographic bone loss. Classify the severity. You cannot treat what you haven't properly assessed.

Step 2 — Non-surgical treatment first. Mechanical debridement, patient re-instruction, risk factor modification. For early to moderate cases, this can arrest progression. Give it time and reassess.

One tool worth knowing: the Galvosurge system uses galvanic current to disrupt and detach the bacterial biofilm from the implant surface — without mechanical abrasion that could damage the implant surface topography. In non-surgical and surgical protocols alike, it adds a layer of decontamination that mechanical debridement alone cannot achieve. For clinicians serious about peri-implantitis management, it belongs in the toolkit.

Step 3 — Surgical intervention for moderate to severe cases. Access surgery to debride the implant surface, resective or regenerative approaches depending on the defect morphology. This is specialised territory — know your limits and refer when appropriate.

Step 4 — Maintenance. After treatment, the patient needs closer monitoring. Peri-implantitis that has been treated is not cured. It is managed. The risk of recurrence is real and requires ongoing vigilance.

Step 5 — Explantation. Sometimes the right answer is removing the implant. A failing implant that cannot be successfully treated is better removed than maintained. It's not failure — it's clinical judgment.

The conversation you need to have

Patients deserve to know that implants are not maintenance-free. The informed consent conversation should include peri-implantitis risk, the importance of hygiene, and the necessity of long-term recall.

Patients who understand this from the start are better partners in their own care. And better partners means better long-term outcomes.

The bottom line

Peri-implantitis is not a rare complication. It is a common one that is largely preventable with careful patient selection, thoughtful prosthetic design, adequate soft tissue management at surgery, and a disciplined maintenance protocol.

Understand it. Respect it. Build your practice around preventing it — and knowing what to do when prevention wasn't enough.

Complication management is part of every Elevate programme. Explore our courses at elevateeducation.be/courses