Peri-implantitis: An Overview of Current Treatment Modalities

Since their introduction in the 20th century, dental implants have drastically changed the approach clinicians have taken toward treating both failing and missing teeth. Now in widespread use around the world, dental implants are known to osseointegrate and provide stable functionality as replacements of single or multiple teeth in both healthy and medically compromised individuals.

With the rising incidence of dental implant treatment, however, comes a growing risk of complications. “Peri-implantitis” describes the inflammatory process that occurs around dental implants, which can lead to progressive loss of alveolar bone and soft-tissue support around the implant. Although the precise definition of peri-implantitis has been debated, the condition is associated with bleeding and/or suppuration around the gingival margin of the implant, increased periodontal probing depth, and progressive bone loss after initial remodeling. The prevalence of peri-implantitis was found to be 22% in a recent systematic review and meta-analysis.¹

Kotsakis and Olmedo stated that peri-implantitis is an immune-mediated complication associated with bacterial biofilm on the implant surface.² Contributing factors such as implant position, foreign body reactions, and debris may also play a role.³ Although periodontitis and peri-implantitis appear similar in their phenotype, the anti-infective therapies that generally would produce a favorable response in periodontitis were found to be less efficacious in the treatment of peri-implantitis. This points toward potential significant differences in the characteristics and progression of peri-implantitis compared with periodontitis.

Studies by Heyman et al using animal (murine) models point toward dysregulation of the immune system as a potential cause of peri-implantitis.^3,4 They found that the peri-implant mucosa exhibited a dysregulated immune response compared with the tissue surrounding natural teeth. In particular, Langerhans cells, which are responsible for maintaining homeostasis in the oral gingiva, were reduced in peri-implant sites. It was suggested that titanium ions released around the dental implant also impair differentiation of antigen-presenting cells.⁴ In other words, the peri-implant environment itself is more susceptible to pathogenesis of peri-implantitis.

The Many Challenges of Peri-implantitis

The multifaceted challenge for clinicians is to restore health to the affected soft and hard tissues by eliminating the pathogenic bacterial biofilm, stabilizing or regenerating the supporting bone, and maintaining healthy peri-implant soft tissues to prevent reinfection of the implant surface.⁵ Complete re-osseointegration of the implant surface is ultimately the ideal outcome; however, this remains difficult to achieve. In many treated peri-implantitis defects, radiographic bone fill represents bony infiltration, in which newly formed bone occupies the defect but is separated from the implant surface by a layer of connective tissue rather than establishing direct bone-to-implant contact. Consequently, true re-osseointegration, defined as direct structural and functional bone contact with a previously contaminated implant surface, is achieved only inconsistently in both experimental and clinical studies.^6,7 Any remnant of bacterial biofilm or endotoxins must be eliminated, and the implant surface must be biologically compatible before re-osseointegration can occur.

Removing biofilm and endotoxins from the implant surface is challenging due to difficulty accessing and navigating the whole defect and because of the macroscopic features and microscopic surface characteristics of the implant itself.⁸ The literature describes several methods for implant surface decontamination or detoxification. These are often mechanical procedures, performed either as standalone detoxification methods or in combination with other chemical or mechanical techniques. Presently, long-term evidence does not demonstrate that any single peri-implantitis treatment modality provides consistently superior clinical outcomes. Animal studies have demonstrated that although radiographic bone fill may occur within peri-implantitis defects following treatment, histologic evaluation often reveals that the newly formed bone is separated from the implant surface by a layer of connective tissue rather than establishing direct bone-to-implant contact; consequently, true re-osseointegration is not consistently achieved.⁹ In animal studies, the rate of re-osseointegration of treated implant surfaces has been between 39% and 46%.¹⁰

This article, the first in a two-part series, discusses currently available modalities for treating peri-implantitis. (Editor’s note: Part 2 of this article, to be subsequently published on compendiumlive.com, will address case examples of peri-implantitis treatment.)

Methods for Treating Peri-implantitis

Mechanical nonsurgical therapy is effective in treating peri-implant mucositis lesions but has been found to be ineffective in treating peri-implantitis lesions.¹¹ Therefore, surgical modalities of treatment would be necessary when peri-implantitis has affected the bone adjacent to the implant. A critical component of peri-implant disease treatment is implant surface biofilm removal and disinfection. For the peri-implantitis osseous lesions to successfully resolve, the contaminated implant surface must be completely disinfected.^12,13 Various methods and agents are described below summarizing current knowledge about these different modalities of peri-implantitis treatment (Table 1).¹⁴

The biofilm associated with peri-implantitis is a highly organized polymicrobial community embedded within an extracellular polymeric matrix that firmly adheres to the implant surface. This matrix protects microorganisms from host immune defenses and antimicrobial agents while facilitating bacterial communication and persistence. The rough microtopography and threaded geometry of implant surfaces further promote biofilm retention and limit access for mechanical instrumentation, making complete decontamination particularly challenging. Consequently, successful peri-implantitis therapy depends on disrupting the biofilm matrix and reducing the microbial burden sufficiently to permit resolution of inflammation and create a biologically compatible implant surface that supports healing. Although numerous chemical and mechanical decontamination methods have been proposed, no single approach has consistently demonstrated superior long-term clinical outcomes, and combination protocols are frequently recommended.^2,12,13

Chemical Surface Decontamination

Various chemicals are available and used clinically to decontaminate exposed implant surfaces and remove oral biofilm that has affixed to those surfaces (Figure 1 through Figure 4).

Saline

Saline has been shown to be effective in implant surface decontamination. A reduction in lipopolysaccharides to levels significantly lower than those of untreated implants has been observed after burnishing a contaminated surface using a cotton pellet soaked in sterile saline for 1 minute.¹¹ However, saline is often used in combination with other agents on affected implant surfaces making it difficult to determine the effect of saline by itself.

Following systemic administration of antibiotics and surgical debridement with saline on peri-implantitis sites in dogs, re-osseointegration reportedly failed to occur due to the presence of bacterial by-products, which caused fibrous encapsulation instead.¹⁵ The authors therefore concluded that re-osseointegration can only occur if the quality of the titanium surface is pristine following surgical debridement. Other studies have shown no difference between saline and citric acid, chlorhexidine, or air–powder abrasive when used in combination with autogenous bone graft and expanded polytetrafluoroethylene (ePTFE) membrane.¹⁶ Thus, saline alone as a decontamination agent has not been demonstrated in the literature as effective, but instead is used frequently as an adjunct for other agents or treatments.

Citric Acid

Having yielded positive results in treating periodontitis, the use of citric acid has carried over to implant treatment.¹⁷ Citric acid has been shown to increase cementogenesis and improve the success of new attachments to root surfaces of teeth affected by periodontitis, as well as inhibit the growth of bacteria on root surfaces of periodontally compromised teeth.¹⁸

Citric acid has also been shown to decontaminate hydroxyapatite surfaces that have been contaminated with bacterial endotoxins from oral biofilm and reduce the total amount of microbes accumulated at titanium surfaces.¹⁹ When citric acid at 40% concentration was compared with ethylenediaminetetraacetic acid (EDTA), cetylpyridinium chloride, hydrogen peroxide, chlorhexidine, and water, it was shown to have the highest capacity for decontamination of Streptococcus mutans biofilm on titanium discs.¹⁴ Further studies are needed to continue discerning citric acid’s efficacy as a surface decontaminant in peri-implantitis lesions.

Chlorhexidine Gluconate

Chlorhexidine gluconate (CHX) is well-known and has proven to be effective in reducing periodontal inflammation and subgingival plaque.²⁰ It is thought to directly interfere with bacterial cell walls, causing cell lysis of those bacteria. CHX is also known for its substantivity, which allows it to be absorbed into hard and soft tissues of the oral cavity and continue to be released for up to 12 hours. CHX has similarly been shown to attach to the surface of titanium implants, which suggests its ability to provide a reservoir for plaque control.²¹

Adverse effects of CHX, however, should be considered when using it for periodontal or peri-implantitis treatment. Krishnamoorthy et al reported that prolonged exposure to CHX may alter the physicochemical properties of titanium implant surfaces by modifying the protective titanium oxide layer, increasing surface corrosion, and changing surface roughness and surface energy.²² These alterations may influence protein adsorption, osteoblast attachment and proliferation, and subsequent healing at the implant surface. In addition, CHX has demonstrated dose-dependent cytotoxic effects on fibroblasts and osteoblasts, potentially impairing soft-tissue healing and early bone regeneration.²³ Consequently, although CHX possesses broad antimicrobial activity, its use should be judicious and limited to clinically appropriate concentrations and exposure times.

Hydrogen Peroxide and Oxidizing Agents

While conventional antimicrobial treatments aim to activate immune defenses and limit microbial growth, oral biofilm may persist and become multi-drug tolerant, presenting a challenge to therapy. Hydrogen peroxide and sodium hypochlorite are widely used for reducing oral biofilm due to their release of free oxygen radicals, which are bactericidal but also do not seem to affect the metallurgical properties of the titanium implant or the surrounding soft tissues.

Oral biofilm is a highly organized polymicrobial community embedded within a self-produced extracellular polymeric substance (EPS) matrix composed of polysaccharides, proteins, lipids, and extracellular DNA. This protective, gel-like matrix firmly adheres to the implant surface, limiting the penetration of antimicrobial agents and other therapeutic materials while shielding resident microorganisms from host immune defenses. In addition, the EPS facilitates bacterial communication through quorum sensing, promotes nutrient exchange, and enables the development of complex multispecies communities with enhanced resistance to environmental stressors. As the biofilm matures, bacteria within the deeper layers exhibit reduced metabolic activity and increased tolerance to antimicrobial agents, making complete eradication increasingly difficult. The roughened microtopography and threaded design of modern implant surfaces further protect the biofilm from mechanical instrumentation, allowing microorganisms to persist within surface irregularities. Consequently, disruption of the extracellular matrix and mechanical removal of the biofilm are essential prerequisites for successful implant surface decontamination, because antimicrobial solutions alone have limited ability to penetrate an intact mature biofilm.^2,24

Hydrogen peroxide can dissolve this matrix to allow access to the underlying bacteria; thus, it has become a commonly used treatment for peri-implantitis, typically at concentrations between 3% and 5% for implant surface decontamination.²⁵ Higher concentrations or prolonged exposure may increase cytotoxicity and soft-tissue injury without demonstrating additional clinical benefit.

Similarly, hypochlorous acid exhibits a comparable oxidative effect and can be applied in peri-implantitis treatment. Hypochlorous acid is also synthesized by neutrophils and macrophages during phagocytosis, where it serves as a potent antimicrobial agent that helps destroy engulfed microorganisms.²⁶

Such chemical treatments with these two solutions cause bacterial cell death and destroy other microorganisms present due to the high concentration of oxygen released. This has an oxidative and disinfecting outcome, killing anaerobic bacteria. Oxidation significantly disrupts the structure and viability of microorganisms.²⁷ After several hours of application of these chemicals, the bactericidal effect of high oxygen concentrations reduces the microorganisms’ effect on the titanium surface of the implant.²⁵ Following implantoplasty on a peri-implantitis-involved implant, the immune system is triggered and local inflammation ensues. This causes local oxygen concentrations to lessen, which eliminates aerobic bacteria at the site. A reduction of the titanium oxide layer to pure titanium also results. Hence, oxygen ingress following the reduction of inflammation causes oxidation of the pure titanium, which may yield varying oxides that are incompatible for re-osseointegration. Therefore, the surface of the implant needs to be treated chemically to return the surface to a state that can readily re-osseointegrate and also to inhibit microbial colonization.²⁵

Subgingival irrigation with hydrogen peroxide has been shown to suppress Actinomyces actinomycetemcomitans.¹⁹ When used in combination with localized antibiotics to clean peri-implantitis sites in human subjects, mean gingival bleeding was significantly reduced in 58% of implants that had 5 years of follow-up or more.¹⁹ The study, however, did not deduce the efficacy of hydrogen peroxide alone.

When hydrogen peroxide and a carbon dioxide laser were used in conjunction and compared with cleaning the implant surface with cotton pellet soaked in saline, both methods yielded similar rates of re-osseointegration. While hydrogen peroxide is effective in cleaning a contaminated implant surface, it also has been shown to increase the surface roughness of titanium discs with prolonged in vitro exposure, which can favor bacterial proliferation.¹⁴ Hydrogen peroxide itself might be cytotoxic toward osteoblastic cells, which are required for bone remodeling and osseointegration.

Mechanical Surface Detoxification

Various mechanical methods used to treat an exposed implant surface when treating peri-implantitis have been reported and documented (Table 2).¹⁴

Abrasive Pumice

In a study comparing application of abrasive pumice using a rotating brush or cotton pellets soaked in saline on peri-implantitis lesions in beagle dogs, both techniques similarly yielded only minimal re-osseointegration and modest resolution of the inflammatory lesion.¹⁵ The effectiveness of pumice abrasion for decontaminating contaminated implant surfaces has been investigated in only a limited number of experimental studies, and current evidence does not support its routine use because no consistent clinical or histologic advantage has been demonstrated over other decontamination methods.²⁸

Air–Powder Abrasive

Originally developed for the removal of extrinsic stains from enamel surfaces, air–powder abrasion was subsequently adapted for periodontal and peri-implant therapy because of its ability to disrupt biofilm, remove surface deposits, and decontaminate exposed root and implant surfaces while producing minimal alterations to the implant surface and surrounding soft tissues when low-abrasive powders such as glycine or erythritol are used.²⁹ The technique has therefore been carried over to peri-implantitis.

Studies have shown that air–powder abrasive decontamination yields reduced pocket depth values at follow-up but not significantly more than other treatment modalities after 3 or 6 months.¹⁰ Air–powder abrasion has been associated with reductions in bleeding on probing and suppuration compared with mechanical debridement using curettes and chlorhexidine irrigation in some randomized clinical trials. However, these findings have not been consistently reproduced, and systematic reviews conclude that the current evidence is insufficient to demonstrate a clear clinical advantage of air–powder abrasion over other implant surface decontamination methods.^30,31

Glycine powder has been the air-abrasive powder advocated for detoxification of implant surfaces when peri-implantitis presents for treatment. Glycine therapy led to early and sustained change in host–microbial interactions that were sustained for a maximum of 3 months.²⁹ Air abrasion with glycine powder was reported to eliminate the most oral biofilm, and minimal alterations across all implant surfaces were reported.²⁹ Glycine powder air abrasion can achieve effective decontamination, providing an environment that enhances bone regeneration even without bone grafting (Figure 5 through Figure 7).³²

Implantoplasty

Implantoplasty involves removing an implant’s exposed threads with rotary instruments (ie, carbide and diamond burs in a high-speed handpiece) and smoothing/polishing the rough implant surface when grafting that would otherwise cover the exposed threads is not part of the treatment plan.³³ This is done to decontaminate the affected implant surface and create a smooth surface supracrestally that is less conducive to plaque adherence.

The process of implantoplasty generates heat and the procedure therefore must be performed with caution to avoid overheating the implant components and affecting the surrounding hard and soft tissues.³⁴ Additionally, implantoplasty alters the physical shape, diameter, and possibly the loading properties of the implant.³⁵ Implantoplasty has been shown to be an effective technique for removing peri-implantitis infection and enabling bone fill at the intrabony defects.

A potential limitation of implantoplasty is the release of titanium micro- and nanoparticles into the surrounding tissues during surface modification. Experimental studies have shown that these particles can activate inflammatory pathways, stimulate the release of proinflammatory cytokines, and impair osteoblast function in a concentration-dependent manner.^36,37 In addition, titanium particles have been associated with alterations in the peri-implant microbiome that may contribute to dysbiosis and persistent inflammation. However, while these biologic effects have been demonstrated in vitro and in preclinical studies, a direct causal relationship between titanium particles generated during implantoplasty and adverse clinical outcomes has not been established. Nevertheless, implantoplasty should be performed with copious irrigation and high-volume evacuation to minimize titanium particle dissemination.^38-40

Galvanic/Electrolytic Cleaning

A novel method for removing biofilm (GalvoSurge® Dental Implant Cleaning System, Straumann, straumann.com) introduced in 2010 utilizes an electrolyte solution (sodium formate) sprayed onto the implant surface and then activated with low-voltage electrical current (Figure 8).⁴¹ The resulting electrolysis reaction splits water into hydrogen anions and cations, producing hydrogen bubbles as well as other disinfecting species, such as tri-iodide and hydrogen peroxide, which lift the biofilm matrix from the implant’s surface. Healthy hard and soft tissues in the surrounding peri-implant environment are spared in this process. Early trials with this system demonstrated good results, with all treated implant sites becoming free from inflammation and significant bone regeneration being achieved.⁴²

An animal study showed that complete re-osseointegration could be achieved after electrolytic cleaning, a result that had not previously been realized with other cleaning methods.⁴³ These histologic findings, however, are limited to animal models thus far. Bony infiltration into the previously infected site must be differentiated from true re-osseointegration. Another study conducted a randomized clinical trial that compared electrolytic cleaning and electrolytic cleaning with air abrasion and found mature bone to be in direct contact with previously infected implants after electrolytic cleaning with or without air abrasion.⁴⁴ In 2021, the authors followed up these cases after 18 months and found no significant clinical difference between electrolytic cleaning with or without air abrasion. They also noted significant reduction in bleeding on probing, suppuration, and radiologic bone level measurement in all cases compared with baseline levels, which may suggest bone fill after electrolytic treatment.⁸

Bosshardt et al found evidence of re-osseointegration in four implants after they were treated with electrolytic cleaning and regenerative therapy with guided bone regeneration.⁷ The implants were explanted 6 to 13 months later after developing recurrent peri-implantitis and the surrounding tissues were studied histologically. This proof-in-principle evidence suggests that re-osseointegration could occur on a previously contaminated implant surface and that the electrolytic cleaning process may even be effective in removing calculus deposits.

When compared with an erythritol jet system (PerioFlow®, EMS Dental, ems-dental.com) and titanium brushes (R-Brush and i-Brush, NeoBiotech, neobiotech.com), the GalvoSurge system performed similarly in removing biofilm of Pseudomonas aeruginosa from implants, according to Assunção et al.⁶ Manual titanium brushes have been noted to cause major surface changes on implant surfaces, and further investigations are warranted to evaluate the effects of these surface changes.⁴⁵ In contrast, Zhu et al examined electrolytic cleaning of biofilm from titanium surfaces and compared it with other techniques, including rotating titanium brush, ultrasonic scaling with metallic tips, ultrasonic scaling with polyether ether ketone (PEEK) tips, and air-polish/abrasion.⁴⁶ Electrolytic cleaning was shown in vitro to remove multispecies biofilm more effectively than conventional mechanical debridement techniques, including air-polishing, ultrasonic instrumentation, and titanium brushing.^44,46

Summary

With a multifactorial etiology and persistent resistance to conventional periodontal therapies, peri-implantitis remains a challenging complication in implant dentistry. As the prevalence of dental implants continues to rise, clinicians must be cognizant of evidence-based protocols to effectively diagnose, manage, and, ideally, reverse peri-implant disease. Early identification and effective management of soft- and hard-tissue inflammatory changes are keys to successfully treating peri-implantitis and preventing progression that leads to loss of the implant.

This comprehensive review outlined current treatment modalities aimed at decontaminating infected implant surfaces, a critical component of both resective and regenerative peri-implantitis therapy. Both chemical and mechanical decontamination techniques demonstrate variable efficacy, with no universally superior method identified to date. While agents such as chlorhexidine, hydrogen peroxide, and citric acid exhibit antimicrobial activity, their potential adverse effects on implant surfaces and surrounding tissues must be carefully considered. Likewise, mechanical modalities such as implantoplasty and air–powder abrasion may effectively reduce biofilm and surface contamination but also carry potential risks, including alteration of implant surface characteristics, release of titanium particles into peri-implant tissues, and possible induction of local inflammatory responses. The biologic significance of titanium particle dissemination remains only partly understood, and clinicians should employ these techniques judiciously, balancing effective decontamination with preservation of implant surface integrity and peri-implant tissue health.

Notably, electrolytic cleaning has emerged as a promising decontamination technique with potential to enable true re-osseointegration, an outcome historically elusive in peri-implantitis treatment. However, despite encouraging preclinical and limited clinical data, long-term human studies are required to validate these findings and establish reproducible protocols.

Ultimately, effective peri-implantitis management will likely require a multifaceted approach tailored to the individual clinical presentation and that combines optimal decontamination strategies with surgical regeneration where indicated. Future research should continue to refine these methods and focus on long-term clinical outcomes with the aim of preserving implant function and improving patient prognosis.

ACKNOWLEDGMENT

Figure 1 through Figure 8 are artificial intelligence (AI)–generated illustrations (ChatGPT) created by the authors.

ABOUT THE AUTHORS

Kenneth Lee, BDS, MSc
Private Practice, Sydney, Australia

Kevin Ka Yiu Shum, BMedSc, DMD
Private Practice, Sydney, Australia 

Gregori M. Kurtzman, DDS, MAGD
Former Assistant Clinical Professor, University of Maryland School of Dentistry, Baltimore, Maryland; Private Practice, Silver Spring, Maryland

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