Peri-Implant Mucositis and Peri-Implantitis: A Current Understandingof Their Diagnosis, Clinical Implications, and a Report of Treatment Using a Combined Therapy Approach

Peri-implant disease can be objectified in 2 distinct forms: peri-implant mucositis and peri-implantitis. When a peri-mucositis occurs, the inflammatory reaction is confined to the soft tissues surrounding an implant, with no signs of loss of supporting bone. This reversible condition is clinically characterized by the presence of bleeding on probing and/or suppuration, which are usually associated with probing depths >_4 mm. Differently, peri- implantitis has been described as a destructive inflammatory process around an osseointegrated implant that leads to peri- implant pocket formation and progressive loss of supporting bone. For defining a case as peri-implantitis, the presence of bleeding on probing and/or suppuration with or without concomitant deepening of peri-implant pockets must be present, in association with peri-implant marginal bone loss 􏰀2 mm from the expected marginal bone level following remodeling after implant placement. In addition to the soft tissues inflammation, the typical bone defect is crater-like, runs all around the implant, and is strictly demarcated; however, implant mobility is absent due to the osteointegration that is maintained apically to the defect.

As different thresholds for probing depths and radiographic bone loss were applied in the literature to diagnose the peri- implant disease, the true incidence cannot be stated. A recent meta-analyses estimated weighted mean prevalences of peri- implant mucositis and peri-implantitis of 43% and 22%, respectively; however, the prevalence ranged from 19% to 65% and from 1% to 47%, respectively, due to the heteroge- neous use of case definitions. Etiopathologically, a cause and effect relationship between biofilm formation on the implants surface and peri-implant disease has been found; however, even nonmicrobial events including implant fractures and submucosal persistence of luting cement could favor the formation of a pathogenic microbiota with the subsequent bacterial insult. It is therefore generally accepted that the elimination of the biofilm from the implant surface is the prime objective when treating peri-implantitis.

Basically, a nonsurgi- cal treatment could be advisable during early phases to treat peri-mucositis; however, if the progression of the peri-implant lesion or the bone loss could not be arrested, surgical therapy may be considered due to its superiority in the treatment of peri-implantitis. Several decontamination methods, such as air- powder abrasion, saline wash, citric acid application, laser therapy, peroxide treatment, ultrasonic/manual debridement, and application of topical medication have all been investigat- ed, but a definite gold standard could not be identified. Furthermore, different regenerative protocols have been used to reestablish a proper amount of bone circumferentially around an implant following surgical therapy; however, results were heterogeneous.