Title: Peri-Implantitis Treatment: Surgical and Non-Surgical Options

Peri-implantitis is a complication affecting dental implants, leading to inflammation and potential bone loss around the implant site. If untreated, it can compromise implant stability and result in failure. Early detection and appropriate intervention are crucial for preserving oral health and implant longevity.

Treatment options range from non-surgical approaches aimed at controlling infection to surgical methods designed to restore lost tissue. Understanding these options helps guide effective management strategies.

Non-Surgical Interventions

Non-invasive treatments are often the first approach, particularly in early stages. These methods focus on reducing bacterial load, controlling inflammation, and preventing further disease progression.

Mechanical Debridement

Mechanical debridement aims to disrupt and remove bacterial biofilm and calculus from the implant surface using titanium curettes, ultrasonic scalers with non-metallic tips, or air-abrasive devices. A study in Clinical Oral Implants Research (2021) found that while mechanical debridement can temporarily reduce inflammation, its long-term effectiveness is limited without adjunctive therapies.

Implant surfaces, especially rough textures, can retain bacterial colonies even after thorough cleaning. Air-polishing with glycine or erythritol powder has become popular as it is less abrasive and can reach difficult areas. However, a Journal of Periodontology (2020) review noted that while air-polishing improves short-term outcomes, it is insufficient as a standalone treatment for moderate to severe cases. Regular maintenance is necessary to prevent reinfection.

Antimicrobial Agents

Antimicrobial therapy is often combined with mechanical cleaning to enhance bacterial eradication. Systemic antibiotics, such as amoxicillin and metronidazole, have shown inconsistent results, and concerns about antibiotic resistance persist. A Journal of Clinical Periodontology (2021) trial found that systemic antibiotics provided minimal additional benefit when combined with mechanical therapy.

Local antimicrobials, including chlorhexidine gels and minocycline microspheres, offer targeted application without systemic side effects. Chlorhexidine reduces bacterial load but may cause implant discoloration and altered taste perception with prolonged use. Minocycline microspheres, which release antibiotics gradually, have improved clinical parameters such as bleeding on probing and pocket depth. However, a meta-analysis in International Journal of Oral and Maxillofacial Implants (2022) concluded that local antimicrobials should be adjuncts rather than replacements for mechanical debridement.

Photodynamic Therapy

Photodynamic therapy (PDT) involves applying a photosensitizing agent followed by light activation to destroy bacterial cells. A Lasers in Medical Science (2021) clinical trial found that PDT, combined with mechanical cleaning, led to greater reductions in pocket depth and inflammation.

PDT selectively targets bacteria without inducing antibiotic resistance. Common photosensitizers include methylene blue and toluidine blue, activated by diode lasers. The process is minimally invasive and does not harm surrounding tissues, though repeated applications may be necessary. While PDT is not yet a standard treatment, ongoing research continues to evaluate its long-term benefits.

Surgical Management

When non-surgical approaches fail or bone loss is significant, surgical intervention is necessary. Open-flap debridement allows direct visualization and removal of granulation tissue, bacterial deposits, and diseased bone, providing a more thorough cleaning than non-surgical methods.

Adjunctive techniques such as saline irrigation, citric acid application, or titanium brushes can enhance decontamination. A Clinical Oral Implants Research (2022) study found that mechanical debridement combined with saline irrigation and air-polishing achieved superior bacterial reduction. Despite these advancements, complete biofilm eradication remains a challenge, particularly on rough-surfaced implants.

For minimal bone loss, resective surgery reshapes the bone and facilitates oral hygiene maintenance. A Journal of Periodontology (2021) analysis reported that resective procedures, combined with implantoplasty—smoothing and polishing the exposed implant surface—reduced pocket depths and improved peri-implant health over five years. However, this method sacrifices some bone volume, which may not be ideal in all cases.

For more extensive defects, guided bone regeneration (GBR) using bone grafts and barrier membranes can restore lost bone. A International Journal of Oral and Maxillofacial Implants (2022) review found that GBR significantly improved implant survival rates, particularly when combined with biologic agents like enamel matrix derivatives or recombinant growth factors. However, regenerative outcomes remain unpredictable and vary based on defect morphology and patient healing capacity.

Laser Techniques

Laser technology decontaminates implant surfaces while minimizing damage to surrounding tissues. Unlike mechanical debridement, lasers disrupt biofilm without surface alterations that could compromise implant integrity. Various wavelengths, including erbium-doped yttrium aluminum garnet (Er:YAG), carbon dioxide (CO₂), and diode lasers, have been studied for their antimicrobial effects.

Er:YAG lasers, which interact effectively with water and hydroxyapatite, remove biofilm while preserving implant surface topography. A Lasers in Medical Science (2021) study found that Er:YAG lasers significantly reduced pocket depth and inflammation compared to mechanical debridement alone.

Diode lasers, operating between 810 and 980 nm, penetrate soft tissues and reduce bacterial load. However, they do not remove calculus as effectively as Er:YAG lasers. Temperature control is crucial, as excessive heat can damage implants and surrounding bone.

CO₂ lasers, with wavelengths around 10,600 nm, effectively decontaminate soft tissues and coagulate blood vessels, reducing post-treatment bleeding. However, they are less commonly used for direct implant decontamination due to potential thermal damage.

Regenerative Methods

Restoring lost bone around compromised implants requires techniques that encourage new tissue formation while maintaining stability. Guided bone regeneration (GBR) is widely used, involving a biocompatible membrane to prevent soft tissue infiltration while promoting osteogenesis.

Bone graft materials play a crucial role, with autogenous grafts considered the gold standard due to their osteogenic potential. However, donor site morbidity has led to increased use of allografts, xenografts, and synthetic substitutes. Xenografts provide a structural framework for new bone deposition, while bioactive ceramics like hydroxyapatite and beta-tricalcium phosphate offer synthetic alternatives with predictable resorption rates.

Biologic agents enhance regeneration. Platelet-rich fibrin (PRF), derived from the patient’s blood, releases growth factors that accelerate healing and graft integration. Recombinant bone morphogenetic proteins (BMPs) stimulate osteoblastic differentiation, though cost and potential side effects limit their use. Some clinicians combine PRF with bone grafts to create bioactive scaffolds for improved regeneration.

Prosthetic Adjustments

When prosthetic factors contribute to peri-implantitis, modifications to the implant-supported restoration may be necessary. Excess cement, improper crown contours, or excessive occlusal forces can promote bacterial accumulation and tissue breakdown.

Residual cement is a common risk factor, as it can trigger localized inflammation if it extends into the peri-implant sulcus. Switching from cement-retained to screw-retained restorations eliminates this risk, allowing easier maintenance. Adjusting crown contours to improve hygiene access can also help reduce plaque accumulation.

Occlusal forces should be carefully managed, as excessive loading exacerbates bone loss. Adjustments, night guards, or splinting multiple implants can distribute forces more evenly, reducing mechanical stress on peri-implant tissues.