Periodontology 2000, Val.

17, 1998, 63-76 Copyright 0 Munksgaard 1998

Printed in Denmark All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

The diagnosis and treatment of

peri-implantitis
ANDREAMOMBELLI P. LANG
& NIKLAUS

Peri-implantitis is defined as an inflammatory pro-
cess affecting the tissues around an osseointegrated
implant in function, resulting in loss of supporting
bone (1st European Workshop on Periodontology
(4)). The term peri-implant mucositis has been pro-
posed for reversible inflammations of the soft tissues
surrounding implants in function. The purpose of
this chapter is to discuss the requirements for diag-
nostic procedures to prevent and intercept these dis-
eases and to outline the options for therapy at differ-
ent stages. This will be based on the hypothesis that
microbial colonization of dental implants and infec-
tion of the peri-implant tissues can cause peri-im-
plant bone destruction and may lead to implant fail-
ure. (Disease conditions associated with implants
not designed for osseointegration, and primary fail-
ures to achieve tissue integration are not discussed
in this chapter.)
Evidence for a microbial cause of
peri-implant infections
Although it is clear that multiple factors can contrib-
ute to implant failure, an increasing number of
studies point to the detrimental effect of anaerobic
plaque bacteria on peri-implant tissue health. There
are essentially five lines of evidence supporting the
view that microorganisms play a major role in caus-
ing peri-implantitis: (i) an experiment in humans,
showing that deposition of plaque on implants can
induce peri-implant mucositis, (ii) the demon-
stration of distinct quantitative and qualitative dif-
ferences in the microflora associated with successful
and failing implants, (iii) placement of plaque-reten-
tive ligatures in animals leading to shifts in the com-
position of the microflora and peri-implantitis, (iv)
antimicrobial therapy improving the clinical status
of peri-implantitis patients, and (v) evidence that the
level of oral hygiene has an impact on the long-term
success of implant therapy (Table 1).
Experimentally induced peri-implant mucositis
The experimental gingivitis model, originally de-
scribed by Loe et al. (55) and representing the ulti-
mate proof for a cause-and-effect relationship be-
tween bacterial plaque accumulation and gingivitis,
was duplicated with regard to the peri-implant situ-
ation (74). Following a period of 6 months with

Table 1. Sources of evidence for a bacterial cause of peri-implantitis

Source References
Experimentally induced peri-implant mucositis: plaque accumulation on implants leads to 12, 74
peri-implant mucositis
-~
Demonstration of distinct quantitative and qualitative differences in the microflora 6, 9, 11, 26, 69, 80, 82, 86, 87
associated with successful and failing implants ~ _ _ _ _
Peri-implant microflora is established shortly after implant placement. Successful implants 1, 7, 13, 47, 60, 65
experience no shifts in microbial composition over time
Periodontal pathogens may be transmitted from residual teeth to implants 7, 37, 38, 49, 64, 75
Induction of peri-implantitis by placement of plaque retentive ligatures in animals 41, 50
Theraw aimed at a reduction of the Deri-implant microflora improves clinical conditions 24, 25, 62
Edentulous patients with poor oral hygiene have more bone resorption around fixtures 52
than do subjects with good hygiene

63
Mombelli & Lang
meticulous plaque control after abutment connec-
tion of two-stage implants, patients were asked to
refrain from all oral hygiene practices for a period of
3 weeks. As a result of plaque accumulation, gingival
indices and probing depths increased around im-
plants and teeth in a very similar way. Hence, a
cause-and-effect relationship between the accumu-
lation of bacterial plaque and the development of
peri-implant mucositis was demonstrated. The
tissue response to de novo plaque formation was also
studied in a beagle dog model (12). The inflamma-
tory infiltrate developing due to the bacterial chal-
lenge was equal in size adjacent to control teeth and
to implants, indicating that the initial host response
triggered in the peri-implant mucosa is equal to that
in gingiva.
Association studies
Successful and failing implants showed marked
differences in the composition of the associated
microflora. Successful implants were sparsely
colonized by gram-positive cocci, whereas failing
implants yielded large amounts of gram-negative
anaerobic bacteria. Fusobacteria, spirochetes and
black-pigmenting organisms such as Prevotella in-
termedia were often found in diseased sites (6, 9,
11, 26, 69, 80, 81, 86, 87). Longitudinal studies
demonstrated that the normal peri-implant micro-
flora was established shortly after implant place-
ment. In successful implants bacterial counts re-
mained low and no shifts in the composition of
the microflora were observed (1, 7, 13, 48, 60, 65).
Data from several studies suggested that peri-
odontal pathogens may be transmitted from re-
sidual teeth to implants (7, 37, 38, 49, 64, 75).
Induction of peri-implantitis in animals
Experimental peri-implantitis was induced in beagle
dogs and monkeys by the placement of ligatures to
enhance plaque accumulation at the mucosal mar-
gin around implants. Lindhe et al. (50) found that
peri-implant lesions develop directly into the al-
veolar bone (in periodontitis lesions intact peri-
odontal fibers usually separate the bone from the
subgingival environment). Lang et al. (41), who in-
duced peri-implantitis and periodontitis in monkeys
with ligatures, reported very similar increases in clin-
ical parameters (plaque and gingival indices, pocket
depth, loss of attachment), changes in histological
features and shifts in the composition of the micro-
flora around implants and teeth.
64
Therapy studies
An increasing number of studies investigate the po-
tential of systemically or topically applied anti-
microbial agents for the treatment of peri-implant
infections. Treatment aimed at a reduction of the an-
aerobic bacteria by mechanical debridement of the
peri-implant pocket and systemic administration of
ornidazole improved clinical conditions (62). In
dogs, systemic amoxicillin and metronidazole com-
bined with local debridement resulted in resolution
of experimentally induced peri-implantitis lesions
(24). Local tetracycline fiber placement also seemed
to have a beneficial effect (25).
Influence of oral hygiene on long-term success
More bone resorption was noted around fixtures in
edentulous patients with poor oral hygiene than in
subjects with good hygiene (52).
Based on this evidence, the following requirements
for implant maintenance and treatment of peri-im-
plant infections can be postulated:
Massive bacterial colonization of implant surfaces
should be avoided to prevent inflammation and
infection of the peri-implant tissues and to mini-
mize the risk for implant failure.
Removal of bacterial deposits is a crucial step in
the therapy of peri-implant infections.
Inducing a change in the local ecology around the
implants to impede massive multiplication of po-
tential pathogens assumes high priority to prevent
disease recurrence.
Features and frequency
The following signs and symptoms are typical for
peri-implantitis lesions:
There is radiological evidence for vertical destruc-
tion of the crestal bone. The defect usually as-
sumes the shape of a saucer around the implant
(Fig. 11, while the bottom part of the implant re-
tains perfect osseointegration. In some instances
wedge-shaped defects develop along the implant
(21). Whether specific patterns of marginal bone
loss indicate a specific underlying cause is not
known. Bone destruction may proceed without
any notable signs of implant mobility until osseo-
integration is completely lost. A continuous peri-
implant radiolucency indicates implant failure (2,
15).
 The diagnosis and treatment of peri-implantitis

type implants after 2 years of function. Twenty-

Fig. 1. Peri-implantitis with typical circumferential bone
defect (“saucerformation”)
eight percent of the patients were diagnosed as
having peri-implant mucositis or hyperplasia.
Seven percent of the I T P (Institut Straumann,
Waldenburg, Switzerland) implants examined 2
years after placement by Weber et al. (96) showed
bone level changes of more than 0.5 mm, and 4%
showed changes of more than 1 mm. Peri-implant
bone loss exceeding 4 mm was reported in 4% to
15% of IMZ and titanium plasma-sprayed implants
used as abutments for mandibular overdentures
after 5 years of function (84). Peri-implant probing
depths exceeding 5 mm were detected in 5% to
20% by the same authors. Thus, the overall fre-
quency of peri-implantitis appears to be in the
range of 5% to 10%. Because the studies not only
vary with regard to the parameters used to define
disease, but also to the selection of subjects and
the length of the observation period, direct com-
parison of implant systems is difficult.

Diagnosis
Vertical bone destruction is associated with the
formation of a peri-implant pocket. Diagnosis implies that a biological phenomenon can
There is bleeding after gentle probing with a blunt be comprehended based on some of its key features
instrument and there may be suppuration from and that this information has an impact on the de-
the pocket. cision on how to improve the situation. An advanced
Tissues may or may not be swollen. Hyperplasia
is frequently seen if implants are located in an
area with nonkeratinized mucosa or if the supras-
tructure is an overdenture (Fig. 2).
Pain is not a typical feature of peri-implantitis.

Estimation of the frequency of peri-implantitis is dif-

ficult and depends on the criteria used to separate
health from disease. A mean crestal bone loss of 0.9-
1.6 mm during the first postsurgery year and bone
loss in the range of 0.02 mm to 0.15 mm in the fol-
lowing years have been reported in numerous
studies on two-stage implants with submerged in-
itial healing phase and are considered normal for
these systems (1-3, 17, 19, 52). A mean loss of 0.09
mm for mandibular implants and 0.01 mm for
maxillary implants has been reported for one-stage
nonsubmerged implants in the second year of ser-
vice (96). Some authors doubt that a firm limit for
an acceptable annual marginal bone loss can be es-
tablished. Quirynen et al. (76) reported higher
amounts of bone loss, which stabilized after 2 to 3
Fig. 2. Peri-implantitis with hyperplastic mucosa. Hyper-
years, and did not lead to fixture failure. plasia is more frequent if implants are located in an area
Smedberg et al. (90) reported radiologically diag- with nonkeratinized mucosa or if the suprastructure is an
nosed marginal bone defects in 6% of BrAnemark- overdenture.
Mombelli & Lang
peri-implantitis lesion is easily diagnosed on the
radiograph by detecting bone loss around the im-
plant. As mentioned before, implant mobility indi-
cates the final stage of peri-implant disease, char-
acterized by complete loss of the direct bone to im-
plant interface. It is evident that peri-implant disease
should be recognized earlier, to allow intervention
before a substantial portion of the supporting bone
is lost. Therefore, diagnostic procedures used around
implants should include sensitive parameters to de-
tect early signs and symptoms of infection.
Peri-implant diagnostic procedures can serve sev-
eral functions: (i) Screening for peri-implant disease
or for factors increasing the risk to develop an unde-
sirable condition, (ii) differential diagnosis of peri-
implantitis and peri-implant mucositis, (iii) treat-
ment planning and (iv) evaluation of therapy and
monitoring.
Screening
Screening procedures have the purpose of identify-
ing possibly diseased subjects or individuals with a
risk of developing disease who would require more
comprehensive examination. Compared with
screening the periodontal conditions around natural
teeth, clinical screening procedures may be less im-
portant for subjects with dental implants. Implant
patients should be recalled on a regular basis, and -
as only a few implants are present in any subject -
clinical examination of all implants requires little
time and can easily be done during the recall ap-
pointment.
Differential diagnosis of peri-implantitis and
peri-implant mucositis
According to the definition, peri-implantitis is an
inflammatory process affecting the tissues around
an osseointegrated implant in function, resulting
in loss of supporting bone. Thus, the differential
diagnosis of peri-implantitis needs discrimination
from reversible inflammation of the soft tissues
with no loss of supporting bone (peri-implant mu-
cositis), primary failures to achieve tissue inte-
gration and problems with no inflammatory com-
ponent. Clinicians may attribute to peri-implantitis
unusual anatomical features, unusual tissue mor-
phology or exposure of parts of the implant due to
resorption or surgical trauma. Such deviation from
the expected may or may not be self-limiting and
may or may not need correction to allow proper
plaque control.
Diagnostic evaluation to plan the intervention
Peri-implant infections may be approached using
various therapeutic methods. These include mech-
anical instrumentation to remove bacterial deposits,
surgical interventions to correct unfavorable tissue
structure, and regenerative procedures to regain lost
tissues. Subgingival antiseptic irrigation as well as
systemically or locally applied antimicrobial agents
may help to fight the bacterial infection. For peri-
odontal therapy it has been shown clearly that each
treatment option has a window of effectiveness,
which seems to be defined primarily by initial prob-
ing pocket depth (51, 73, 78). Based on this experi-
ence, it is conceivable that also certain methods for
peri-implant treatment produce best results only
within a given range of diagnostic parameters. Anti-
microbial drugs should only be used based on a
sound knowledge of the implicated microorganisms
(27, 28).
Evaluation of therapy and monitoring
Diagnosis after treatment has two aspects. The first
aspect is the evaluation of active therapy when the
clinician has to decide whether or not treatment is
really completed. In this situation, reductions in
probing depth, bleeding tendency and reduction or
elimination of putative pathogens might be con-
sidered. The second aspect is long-term monitoring.
In this situation the clinician must decide if the in-
itial treatment result has long-term stability. There-
fore, indicators for stability in tissue dimensions are
desired, and radiographic parameters such as bone
levels and bone density assume greater importance.
Diagnostic parameters
Peri-implant radiography
The preservation of marginal bone height is con-
sidered crucial for implant maintenance and is often
used as a primary success criterion for implant sys-
tems. Vertical bone loss of less than 0.2 mm annually
following the implant’s first year of service has been
proposed as one of the major criteria for success (5,
47). Longitudinal studies have demonstrated that
two stage and one stage implant systems can fulfill
this requirement (1-3, 17, 19, 52, 96). For the accu-
rate assessment of bone level changes, longitudinal
series of standardized radiographs are required. De-
tection of minute changes of bone level or density
requires a reproducible projection geometry for the

Table 2. Cumulative interceptive supportive therapy
~~
Plaque Bleeding
Cumulative interceptive supportive therapy modalities
A Mechanical cleansing and improvement of patient’s oral hygiene. Removal of hard deposits with soft scalers, polishing with rubber cup and paste.
Instruction for more effective oral hygiene practices.
B Antiseptic therapy Rinses with 0.1-0.2% chlorhexidine digluconate, pocket irrigation with 0.2% chlorhexidine or local application of chlorhexidine gel
C Antibiotic therauv. Svstemic aeent selected on the basis of a microbioloeical test or treatment with local deliverv device.
D Surgical therap; io ihange tissue structure. Gingivectomy, apically repositioned flap, osteoplasty or guided bone regeneration procedure
E Explantation.
X-ray beam, provided by an appropriate aiming de-
vice. This high level of sophistication is usually only
used for research purposes. It is important to note
that the above-mentioned mean annual bone height
changes in the range of 0.1 mm are only mathemat-
ically determined and cannot be detected by com-
parison of two radiographs from a single implant. In
addition, because of concerns about undue exposure
of subjects to radiation, radiographs cannot be taken
at every recall visit. Thus, radiographic examination
cannot be the only parameter to estimate the per-
formance of implants in the individual patient. In
the absence of clinical signs of infection it is rec-
ommended to take radiographs 1 year after implant
installation and not more than every other year
thereafter. Additional radiographs should only be
taken to determine the extent of marginal bone loss
if clinical parameters (increased probing depth) indi-
cate signs of peri-implant infection.
Peri-implant probing
In addition to the evaluation of bone levels on radio-
graphs, peri-implant probing has been suggested as
a useful diagnostic procedure (4, 63). Probing the
peri-implant sulcus with a blunt, straight peri-
odontal probe allows the assessment of the following
parameters:
peri-implant probing depth;
distance between the soft tissue margin and a ref-
erence point on the implant (measurement of soft
tissue hyperplasia or recession);
bleeding after probing; and
exudation and suppuration from the peri-implant
space.
The diagnosis and treatment of peri-implantitis
Pocket depth
Pus (mm) Bone loss Therapy
It has been noted in many studies that successful
implants generally allow probe penetration of ap-
proximately 3 mm (2, 8, 16, 19, 22, 23, 30, 59, 65, 69).
The extent of peri-implant probe penetration was in-
vestigated in dogs in a histological study (44). The
results indicated that the density of the peri-implant
tissues influenced penetration depth. In the pres-
ence of inflamed tissues around one-stage nonsub-
merged implants, periodontal probes penetrated
close to the bone level. If healthy tissues were pres-
ent, the probe tips tended to stop at the histological
level of connective tissue adhesion. Correlations be-
tween the level of bone as seen on radiographs and
the extent of peri-implant probe penetration have
been noted. In the case of screw-type implants, the
probe tip appeared to stop 1.4 mm coronally to the
bone level (77). The mean discrepancy between
probe penetration and the location of the bone mar-
gin in radiographs was 1.17 mm in 100 nonsub-
merged hollow screw and hollow cylinder implants
measured 1 year after implantation (16). Microbio-
logical studies have shown that there is a marked
difference in the composition of the peri-implant
microflora between implants with deep and shallow
pockets (6, 11, 69, 80, 82, 87). Pockets 5 or more mm
deep can be viewed as protected habitats for puta-
tive pathogens and are a sign of peri-implantitis.
It has been shown that the magnitude of probe
penetration into a periodontal pocket depends on
the force applied to the instrument (61, 92). Simul-
taneous recordings of probing depth and probing
force before and after periodontal therapy have fur-
thermore revealed that the force range chosen for
repeated probing influences the amount of attach-
ment level change determined (68, 66). The tissue
resistance to probing and the accuracy of depth de-
67
Motnbelli st Larig

rnm -T gated in longitudinal trials (10, 40). Although bleed-

ing failed as a predictor of disease activity, it was
6T A 1

found that absence of bleeding was a clinically use-

N force for the determination of bleeding on probing
0.25 0.50 0.75 1 .oo 1.25
Fig. 3. Mean depth force curves obtained from implants
(0) and teeth (0)together with the respective b values
(arrows).The b-value represents an indicator for the force
dependence of probing depth measurements. When using
any probing force above the b-value, less than 0.5 mm
difference in depth reading should occur. The b-value is
higher for implants (I) than for teeth (T), indicating a
greater susceptibility of peri-implant probing readings to
variation in probing force (67).
ful indicator of periodontal stability. Bleeding on
probing represents a clinical parameter defined as
the reaction of the soft tissue seal following the
penetration of a periodontal probe into the peri-im-
plant sulcus or pocket by using a gentle force. The
size (point diameter) of the probe as well as the ap-
plication force should be standardized. For teeth, a
probing force of 0.25 N has been recommended (43,
36). It appears reasonable to use the same probing
around oral implants.
Probing depth measurements related to a fixed
landmark on the implant and examination of the
bleeding tendency of the peri-implant tissues seem
to be well-suited for the longitudinal monitoring of
peri-implant stability. Standardized probes such as
the Audio Probe, the TPS Probe or the HAWE Click
Probe may be recommended.

Mobility
termination at different force levels was compared Implant mobility is an indication for lack of osseoin-
around implants and teeth in 11 subjects (67).SU~CUS tegration. Even if disease conditions in the peri-im-
depth measurements were performed around im- plant tissues have progressed relatively far, implants
plants and teeth at comparable locations with a may still appear immobile due to some remaining
specifically designed probing device allowing real- direct bone-to-implant contact. Mobility is thus in-
time recording of probe penetration as a function of sensitive in detecting the early stages of peri-implant
probing force. An aiming device provided standard- disease. The parameter rather serves to diagnose the
ized projection geometry to take a radiograph with final stage of osseodisintegration and may help to
the probe tip in the sulcus. The standard error of the decide that an implant has to be removed. Implants
individual measurement (SJ, evaluated by compari- connected by fixed reconstructions to teeth or other
son of repeated measurements in the same session,
was 0.2 mm on implants and 0.1 mm on teeth. For
implants there was a trend for slightly better repro-
ducibility at higher force levels. Curve analysis of
depth force patterns showed that a change in prob-
ing force had more impact on the depth reading in
the peri-implant than in the periodontal situation
(Fig. 3). The mean distance between the probe tip
and the peri-implant bone crest amounted to
0.7550.60 mm at 0.25 N probing force (Fig. 4). It was
concluded that peri-implant probing depth meas-
urements are more sensitive to force variation than
periodontal pocket probing (67).
Differences in the tendency of the periodontal
tissues to bleed after mechanical irritation by prob-
ing have been the subject of investigation of several
studies (10, 29, 32, 35, 40, 42, 43, 83, 93-95). The as- Fig. 4. Standardized radiographs from a tooth and an im-
sociation between bleeding at multiple probing visits plant with the probe tip inserted with a force of 0.25 N
and subsequent loss of attachment has been investi- (67)

implants will not show their full range of mobility.
For the interpretation of low degrees of mobility, an
electronic device has been proposed, which was
originally designed to measure the damping charac-
teristics of the periodontium of natural teeth (Peri-
otest@,Siemens AG, Bensheim, Germany). Signifi-
cant differences in Periotest scores have been re-
ported for implants in the mandible and the maxilla
(16). In patients with BrAnemark-type implants, Peri-
otest readings were found to be related to character-
istics of the mandible, the peri-implant tissue and
the length of the abutment (91). The prognostic
value of Periotest readings for peri-implantitis re-
mains to be determined.
Suppuration
Histological examinations of periodontal tissues
show an infiltration with neutrophils whenever dis-
ease is present (88). High numbers of leukocytes
have been shown also with implants that have in-
creased gingival inflammation (82). Studies using
biochemical markers of neutrophil presence indicate
an association between periodontal disease activity
and high levels of the neutrophil enzyme p-glucu-
ronidase (39). This suggests that suppuration is as-
sociated with disease activity and indicates a need
for anti-infective therapy.
Clinical indices
Swelling and redness of the marginal tissues have
been reported from peri-implant infections in ad-
dition to pocket formation, suppuration and bleed-
ing (69,82). Recognition of these signs has been con-
sidered important in the diagnosis of periodontal
disease. Parameters developed for teeth are not
strictly applicable to the features of tissues encoun-
tered around implants. It seems reasonable to define
peri-implant parameters based on periodontal indi-
ces such as the Sulcus Bleeding Index (70) or the
Gingival Index (54). The bleeding tendency of the
marginal peri-implant tissues can be assessed using
the modified Sulcus Bleeding Index (69). An index
for assessing peri-implant mucosal tissues based on
the Gingival Index, but without incorporating the
bleeding criterion, has also been proposed (8). Scor-
ings from teeth and implants should be handled and
interpreted separately. The texture and color of
tissues, which are important discriminators between
Gingival Index scores, depend on the normal ap-
pearance of the recipient tissues before implantation
and may vary due to properties of the implant sur-
The diagnosis and treatment of peri-implantitis
face. The modified Plaque Index (69) may be used to
assess the amount of plaque on implants.
Microbiology
Bacterial culture, DNA probes, polymerase chain re-
action, monoclonal antibody and enzyme assays to
monitor the subgingival microflora have been pro-
posed to determine an elevated risk for periodontal
disease or peri-implantitis. The capacity of micro-
biological parameters to predict future attachment
loss around natural teeth has been investigated in
several trials, but most of them involved subjects al-
ready suffering from periodontitis. In some studies
it was possible to demonstrate that high levels of
Porphyromonas gingivalis, I? intermedia and Actino-
bacillus actinomycetemcomitans increased the risk
for further attachment loss in maintenance patients
(14, 89, 97). In other studies spirochete counts were
correlated with disease progression (53). At present,
too little is known to make a definitive statement re-
garding the benefit of microbiological tests as a pri-
mary tool in determining the risk for peri-implant
tissue loss.
The value of microbiological testing is substan-
tially different after clinical or radiological signs of
disease have been detected and the clinician has to
decide how to deal with the problem. Studies indi-
cating the existence of different forms of peri-im-
plant disease, including specific infections (79) and
nonbacterial failures (85), illustrate that microbio-
logical tests may be valuable tools for the differential
diagnosis of peri-implantitis and for planning treat-
ment. It is biologically sound and good medical
practice to base systemic antimicrobial therapy on
appropriate microbiological data. Microbial testing
should be comprehensive and sensitive enough to
determine the presence and relative proportion of
the most important periodontal organisms. Since the
antimicrobial profiles of most putative periodontal
pathogens are quite predictable, susceptibility test-
ing is not routinely performed.
Continuous diagnosis
Rationale for a stepwise approach
As the preceding section has shown, various diag-
nostic methods, ranging from the traditional assess-
ment of bone features on radiographs over clinical
measurements to biological assays, are available for
peri-implant diagnosis. Intuitively, one tends to be-
lieve that the more information one has about a pa-
69
Mombelli & Lang
tient, the better one can care for him or her. HOW-
ever, the indiscriminate application of tests, leading
to more work, inconvenience and increasing costs,
may also reduce the overall quality of service. Many
efforts have been made in recent years to determine
the sensitivity, specificity and predictive value of di-
agnostic procedures to indicate disease or an in-
creased risk for disease. Based on such findings, in-
ferences have been drawn regarding the practical
value of the tests. However, in this context it is im-
portant to emphasize that the usefulness of a test
not only depends on sensitivity, specificity and pre-
dictive value. The result of a sensitive and specific
test may be invaluable in one clinical situation and
yet worthless in another. Among other things, the
benefit of a test depends on the level of diagnostic
certainty already achieved before the test is done. It
is therefore important not only to choose the right
set of tests for peri-implant diagnosis but further-
more to define the role of each test within the de-
cision process. As discussed above, microbiological
tests to determine the composition of the peri-im-
plant microflora may have little value as primary dis-
ease indicators in implant wearers with no clinical
signs of infection. Once clinical parameters indicate
infection, however, microbiological information may
be very helpful to choose an appropriate antibac-
terial therapy.
The decision process for peri-implant diagnosis
A possible decision process for peri-implant diag-
nosis is outlined in the following section. It is used
to discuss the relative requirements for specific diag-
nostic information, depending on different options
for therapy at the various stages of disease. It is sug-
gested that the clinician start the diagnostic pro-
cedure with the following question (Fig. 5):
Are there peri-implant pockets deeper than
3 mm?
Successful implants generally allow probe penetra-
tion of approximately 3 mm, and the location of the
peri-implant bone level can be expected about 1 mm
apical to the position of the probe tip. The presence
or absence of plaque and the bleeding tendency of
the peri-implant tissues are the two additional par-
ameters to be considered if pockets are not deeper
than 3 mm. If an implant yields negative results, one
can assume that the implant surface is sparsely
colonized by nonpathogenic gram-positive cocci,
that the peri-implant tissues are not inflamed, and
that the risk for peri-implant problems is low. Thus,
70
no therapy is needed and one may consider increas-
ing the length of the recall interval. In such cases
radiographs can usually be limited to a minimum of
one every other year. If plaque andlor an increased
tendency of the peri-implant tissues to bleed is de-
tected, this is an indication of suboptimal oral hy-
giene. In this case the implants should be mechanic-
ally cleaned using a rubber cup and polishing paste.
Instruments made of a material softer than titanium
may be used to remove hard deposits. Oral hygiene
practices should be checked, and the proper plaque
control technique should be instructed and re-
inforced.
One should consider that implant shape and sur-
face texture influence the penetration of the probe
tip. A rough surface or the presence of threads may
lead to underestimation of pocket depth. If a peri-
odontal probe penetrates beyond the 3-mm mark,
the next question is:
Is it peri-implantitis?
The differential diagnosis of peri-implantitis requires
discrimination from reversible inflammations of the
soft tissues with no loss of supporting bone (peri-
implant mucositis), primary failures to achieve
tissue integration and conditions without an in-
flammatory component. Displacement of soft
tissues or loss of supporting bone may be due to re-
sorption or surgical trauma experienced before im-
plant placement. An exposure of larger parts of the
implant body may be related to difficulties associ-
ated with implant placement. Unfavorable tissue
morphology may hinder the patient’s plaque control,
which may lead to mucositis and may represent a
risk for peri-implantitis. Thus, after an evaluation of
implant position in relation to the topography of the
peri-implant tissues, a systematic collection of clin-
ical information regarding the following items
should follow:
Is there inflammation?
Is there another process imitating peri-im-
plantitis by pseudo-pocket formation?
Is there loss of peri-implant bone?
Is there a plausible cause for bone loss other
than peri-implantitis?
Presence of plaque and an increased tendency of the
peri-implant tissues to bleed indicate the presence
of inflammation caused by suboptimal oral hygiene.
Probing depths in the range of 4 to 5 mm may be
caused by tissue swelling and may be corrected by
improvement of peri-implant plaque control. In the
presence of pus, or if pocket depths exceed 4 to 5

slji
z
V 1
. .
Fig. 5. Decision process for peri-implant diagnosis. The
initial assessment includes peri-implant probing, evalu-
mm, additional anti-inflammatory measures, includ-
ing the application of antiseptics, may be indicated.
Thus, radiographs will be indicated to evaluate peri-
implant bone morphology. If there is clear evidence
of bone loss, then the next question is:
Is there evidence for a specific (microbial) cause
of this condition?
Specific microbial information regarding the pres-
ence of putative pathogens will be indispensable at
this point to make a meaningful decision regarding
The diagnosis and treatment of peri-implantitis
0 . . ..
3 Q
ation of oral hygiene and the bleeding tendency of the
peri-implanttissues.
systemic or local antibiotic therapy. Although the
composition of the subgingival microbiota will be
important for the choice of the drug, oral distri-
bution patterns of potential pathogens will be im-
portant in deciding whether an antimicrobial agent
should be administered locally or systemically. To
accomplish this task the clinician needs to look at
the periodontal condition of the residual teeth. Pa-
tients suffering from localized peri-implant prob-
lems in the absence of other infections may be can-
didates for treatment by local drug-delivery devices.
71
Mombelli 8 Lang
mrn
Peri-implant probing depth
61 T 220% gram-negative anaerobic bacteria, in diseased
.i
1
0 0
0 1 2 3 4 5 6 7 8 9 1011
Months
Z:rnBI
21 Modified Bleeding Index
'
01 0 1 2 3 4 5 6 7 8 9 1011
Months
Fig. 6. Effect of antimicrobial treatment on peri-implant
probing depth and the bleeding tendency in patients with
peri-implantitis.Between baseline and day 10 the patients
received 1000 mg of ornidazole daily (62).
Cumulative treatment
Owing to the fact that the frequency of late implant
failures is relatively low, the number of longitudinal
studies evaluating different treatment protocols for
peri-implantitis is limited. Furthermore, ethical con-
siderations often disallow the incorporation of
proper placebo control in such trials.
Subgingival irrigation of the peri-implant space
with antiseptic agents has been advocated by many
clinicians. A 3-month double-blind parallel study in-
cluding 20 subjects without peri-implantitis (mean
peri-implant probing depths <2 mm) showed sig-
nificant reductions in Plaque Index, Gingival Index
and Bleeding Index in subjects using an antiseptic
mouthrinse in addition to their normal oral hygiene
regimen (18).In an 8-week longitudinal study involv-
ing 30 hydroxyapatite-coated implants with peri-im-
plant probing depths >3 mm, however, no clinical
or microbiological effect could be demonstrated for
irrigation with 0.12% chlorhexidine (45).
A systemic antimicrobial treatment approach was
tested in a study involving nine patients with marked
loss of bone and pocket probing depths 2 5 mm
around implants (62). These patients were selected
based on microbiological screening; individuals were
only considered if they had anaerobic cultivable
72
counts P lo6 colony-forming units per ml, including
sites. The treatment included mechanical debride-
ment, irrigation of all peri-implant pockets >3 mm
with 0.5% chlorhexidine and systemic antimicrobial
therapy with an agent specifically effective against
strict anaerobes (ornidazole, 1000 mg for 10 con-
secutive days). After therapy, bleeding scores im-
12 mediately decreased. Over a 1-year observation
period they remained significantly lower than before
treatment. A significant gradual reduction in mean
probing depths was detected over this 1-year period
(Fig. 6). Only one case showed no improvement of
local probing depth. Microbiological parameters in-
dicated an instantaneous quantitative and qualita-
tive change following treatment. Subsequently, sev-
eral of these parameters tended to shift back towards
12
pretreatment values. In the second half of the obser-
vation period, however, this tendency was reversed,
and levels significantly different from baseline were
eventually established.
It is currently being investigated whether peri-im-
plant infections may be treated using controlled-de-
livery devices for the local application of tetracy-
cline. Such devices can release a sustained high dose
of the antimicrobial agent precisely into the affected
site during several days. Case reports and prelimi-
nary data indicate a potential benefit of this form of
therapy (25).
Mechanical instrumentation to remove bacterial
deposits may damage the implant surface if per-
formed with metal instruments harder than titanium
(56). In a comparative in vivo study, the surface tex-
ture of titanium implant abutments was evaluated
after exposure to plastic scalers, an air-powder
abrasive system or polishing with rubber cup and
pumice. None of these methods appeared to
roughen the surface. The rubber cup with pumice
provided the smoothest polished abutment surface
(58).
Once the inflammatory process in the peri-im-
plant tissues is under control, an attempt may be
made to improve or re-establish osseointegration
using regenerative procedures. An increasing num-
ber of reports document the clinical or radiological
success of regenerative treatment of peri-implantitis
lesions (31, 33, 46, 57). However, histological evi-
dence of true re-osseointegration in humans is still
lacking. Attempts to regenerate bone around im-
plants have been evaluated histologically in dogs
with experimentally induced peri-implantitis. In one
study (341, some reosseointegration was noted on a
previously contaminated implant surface. In another

study, however, only a dense connective tissue cap-
sule was found in this area (72). Despite the fact that
the infection had been treated using antibiotic and
antiseptic agents, new direct bone-to-implant con-
tact was not obtained coronal to the bottom of the
lesion (24).
Nowzari & Slots (71) determined the microbiota
on membranes used for guided bone regeneration
in extraction or dehiscence defects around implants.
Microbiological findings were compared with the
clinical success of therapy. The presence of putative
periodontal pathogens was associated with unsuc-
cessful guided bone regeneration. (Several other
studies deal with the treatment of implant dehis-
cence defects, or demonstrate the possibility for
bone augmentation before or concomitant with im-
plant placement. An extensive discussion of these
studies goes beyond the topic of this chapter.)
Incomplete surface decontamination seems to be
the major obstacle for growth of bone onto pre-
viously exposed implants. Although this problem has
been approached by in u h o experiments (20, 9%-
loo), the biological requirements for direct re-growth
of bone remain largely unexplored. To make further
advances in the treatment of peri-implant defects by
guided tissue regeneration, more information is
needed to establish the proper conditioning pro-
cedures for reosseointegration.
Cumulative interceptive
supportive therapy
The following is a presentation of the method for im-
plant maintenance and therapy of peri-implantitis
currently used and evaluated for efficacy at the
School of Dentistry, University of Berne, Switzerland.
The principle of this method is to detect peri-im-
plant infections as early as possible and to intercept
the problems with appropriate therapy. The basis for
this system is a regular recall of the implant patient
and the repeated assessment of the following key
parameters around each implant (Fig. 7): the pres-
ence of plaque, the bleeding tendency of the peri-
implant tissues, suppuration, the presence of peri-
implant pockets and radiological evidence of bone
loss. Optimally an implant should yield negative re-
sults for all of these parameters. In this case no ther-
apy is needed and one may consider increasing the
length of the recall interval. If plaque and/or an in-
creased tendency of the peri-implant tissues to bleed
is detected then the implants are mechanically
The diagnosis and treatment of peri-implantitis
cleaned using a rubber cup and polishing paste. In-
struments made of a material softer than titanium
may be used to remove hard deposits. Oral hygiene
practices should be checked, and the proper plaque
control technique should be instructed and re-
inforced (A). In the presence of pus, or if first signs
of peri-implant tissue destruction are detected
(pockets in the range of 4 to 5 mm and slight bone
loss) regimen A should be combined with the appli-
cation of a local antiseptic (B). The peri-implant
pockets are irrigated with 0.2% chlorhexidine and
the patient is advised to rinse twice daily with 0.1-
0.2% chlorhexidine. If possible, the patient is in-
structed to irrigate the peri-implant area daily using
a syringe with a blunt cannula. Alternatively the pa-
tient may be advised to apply chlorhexidine gel. If
the peri-implant sulcus allows more than 5 mm of
penetration of a periodontal probe then a radio-
graph is taken. If there is clear evidence of bone loss,
then a microbiological sample is taken. Should there
be evidence of an anaerobic flora, the patient is
given treatments A and B, and, in addition, is placed
on systemic antimicrobial therapy (C) with an agent
specifically effective against strict anaerobes (ornid-
azole, 1000 mg for 10 consecutive days). If the bone
destruction has advanced considerably, surgical in-
tervention to correct the tissue morphology or to ap-
ply guided bone regeneration techniques may be
necessary (D). Such treatment would, however, only
be given in addition to the other measures (A, B and
C). The goal of this cumulative treatment approach
is to intercept peri-implant tissue destruction as
early as possible and to avoid explantation (E) due
to loss of osseointegration.
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