The implant should be cleaned by instruments softer than titanium, such as polishing with a rubber cup and paste, floss, interdental brushes, or using plastic scaling instruments. These have been shown not to roughen the implant surface unlike metal and ultrasonic scalers.[11] Although implant surface damage can almost be prevented by using either ultrasonic scalers with a nonmetallic tip or resin/carbon fiber curettes, the presence of implant threads and/or implant surface roughness may compromise the access for cleaning.[12]

The study by Karring et al.[13] demonstrated that sub-mucosal debridement alone, accomplished by utilizing either an ultrasonic device or carbon fiber curettes, is not sufficient for the decontamination of the surfaces of implants with peri-implant pockets ≥ 5 mm and exposed implant threads. So it seems reasonable to suggest that mechanical or ultrasonic debridement alone may not be an adequate modality for the resolution of peri-implantitis.

Four implant surface decontamination methods were compared in a monkey model: (1) air-powder abrasive technique followed by citric acid application, (2) air-powder abrasive technique, (3) gauze soaked in saline followed by citric acid application, and (4) gauze soaked alternately in 0.1% chlorhexidine and saline.[14] Clinical parameters, radiography (including quantitative digital subtraction radiography), histology, and stereology did not reveal significant differences between any of the methods used. Findings from an in vitro study combining photosensitization by toludine blue solution and soft laser irradiation have indicated that elimination of bacteria from different titanium surfaces without modification of the implant surface was possible.[15]

Photodynamic therapy is a non-invasive method that could be used to reduce microorganisms in peri-implantitis.[16] 2% chlorhexidine or 3% hydrogen peroxide can be used as topical antiseptics. Decontamination of affected implants with titanium plasma-sprayed or sandblasted/acid-etched surfaces may most easily and effectively be achieved by applying gauze soaked alternately in chlorhexidine and saline.[12]

The non-surgical treatment of peri-implantitis lesions using an erbium-doped:yttrium, aluminum, and garnet (Er:YAG) laser showed lower counts of F. nucleatum 1 month after therapy.[17] According to Schwarz et al.,[18] the Er:YAG laser and the combination of mechanical debridement/chlorhexidine are equally efficacious at 6 months after therapy in significantly improving peri-implant probing pocket depth and clinical attachment level, but the use of the Er:YAG laser provides a significantly higher reduction of bleeding on probing compared with the adjunctive application of chlorhexidine. However, in a subsequent study by Schwarz et al.,[19] the efficacy of the Er:YAG laser appeared to be limited to a 6-month period, particularly for advanced peri-implantitis lesions. It was further suggested that a single course of treatment with the Er:YAG laser may not be adequate for achieving a stable therapy of peri-implantitis and that additional therapeutic measures, such as supplementary use of the Er:YAG laser and/or subsequent osseous regenerative procedures, might be required.

Specific microbial information regarding the presence of putative pathogens is indispensible to make a meaningful decision regarding systemic or local antibiotic therapy. Although the composition of the subgingival microbial component is important for the choice of the drug, oral distribution patterns of potential pathogens are also important in deciding whether an antimicrobial agent should be administered locally or systemically. To accomplish this task, clinician needs to look at the periodontal condition of the residual teeth.

The study by Schwarz et al.[18] demonstrated that the treatment of peri-implant infection by mechanical debridement with plastic curettes combined with antiseptic (0.2% chlorhexidine) therapy may lead to statistically significant improvements in bleeding on probing, peri-implant probing pocket depth, and clinical attachment level at 6 months compared with baseline. A study by Renvert et al.[20] showed that the addition of antiseptic therapy to mechanical debridement does not provide adjunctive benefits in shallow peri-implant lesions where the mean probing pocket depth was <4 mm. Thus, it seems that the addition of antiseptic therapy to mechanical debridement does not provide adjunctive benefits in shallow peri-implant lesions with mean pocket probing depth <4 mm but seems to provide additional clinical improvements in deep peri-implant lesions with mean pocket probing depth >5 mm.

Patients suffering from localized peri-implant problems in the absence of other infections may be candidates for treatment by local drug-delivery devices. Local application of antibiotics by the insertion of tetracycline fibers for 10 days[5] can provide a sustained high dose of the antimicrobial agent precisely into the affected site for several days. The use of minoccline microspheres as an adjunct to mechanical therapy is beneficial in the treatment of peri-implant lesions, but the treatment may have to be repeated.[21] The study by Renvert et al.[20] demonstrated that the adjunctive benefits derived from the addition of an antibiotic minocycline to mechanical debridement tend to be greater, although to a limited extent, than those achieved by the combined use of an antiseptic (chlorhexidine) and mechanical debridement. The improvements in peri-implant probing depths obtained by the adjunctive use of minocycline can be maintained during a short-term period of 12 months. In the study by Renvert et al.,[20] the exhibited bone loss was not more than three implant threads.

If the problem is generalized, specific microbiological information is collected and antibiotics are administered systemically. Lang et al.[5] suggest the following antibiotic regimes: systemic ornidazole 500 mg bd for 10 days or metronidazole 250 mg td for 10 days or a once daily combination of metronidazole 500 mg and amoxicillin 375 mg for 10 days. If peri-implantitis is associated with persisting periodontal disease, then both conditions need to be treated. In this case, the adjunctive use of systemic antibiotics may be considered. There are no clinical trials available nowadays on the systemic administration of antibiotics for the therapy of peri-implantitis.

Provided that mechanical and antiseptic protocols are followed prior to administering antibiotic therapy, it appears that shallow peri-implant infection may be successfully controlled using antibioics.[1] But it is still open to question whether deeper peri-implant lesions can be adequately treated non-surgically by a combination of a local antibiotic and mechanical debridement.

Surgical resection is generally confined to implants placed in non-aesthetic sites.[22] Surgical flap helps in comprehensive debridement and decontamination of the affected implant. Surgical therapy was carried out, using: (1) autogenous bone grafts covered by membranes, (2) autogenous bone grafts alone, (3) membranes alone, and (4) a control access flap procedure showed that defects treated with membrane-covered autogenous bone demonstrated significantly larger amounts of bone regeneration and reosseointegration than those treated with the other three procedures.[12] However, membrane exposure is a frequent complication after such procedures. Exposure of porous e-PTFE membranes may result in bacterial penetration and lead to infection.[23]

To date, no randomized controlled clinical trials are available on the use of access flap surgery (open-flap debridement) alone for the therapy of periimplantitis. A randomized comparative clinical trial by Romeo et al.[2425] concluded that resective surgical procedures coupled with implantoplasty could have a positive influence on the survival rates of rough-surfaced implants affected by peri-implantitis as well as on peri-implant clinical parameters, such as pocket-probing depth, suppuration, and sulcus bleeding. The study by Schwarz et al.[26] demonstrated that both nanocrystalline hydroxyapatite and guided bone regeneration provided clinically significant improvements in clinical parameters following 6 months of non-submerged healing. The 2-year results by Schwarz et al.[27] of the same clinical study once more demonstrated that both treatment modalities were efficacious in providing clinically significant reductions of pocket-probing depth and gains in clinical attachment level, but the application of the combination of natural bone mineral and collagen membrane seemed to correlate with greater improvements in those clinical parameters and, hence, was associated with a more predictable and enhanced healing outcome. Unfortunately, the relatively small sample size of the study (22 patients) did not allow a reliable statistical comparison of the efficacy of the two therapeutic procedures. In general, more data on various regenerative techniques for treating peri-implantitis have to be accumulated.

If there is advanced bone loss and the implant cannot be saved, it has to be removed. If a decision has been made to remove the implant, explantation trephines are available to suit the implant system concerned. It should be noted that these trephines have an external diameter of up to 1.5 mm greater than the diameter of the implant to be removed. Thus, explantation may be associated with significant bone removal including buccal or lingual bone cortices, and damage to adjacent natural teeth where the inter-radicular space is limited. An alternative approach is to allow progressive bone loss from peri-implantitis to occur, resulting in sufficient bone loss to allow for the removal of the implant with extraction forceps. Implants may be removed by forceps when there is less than 3 to 4 mm of residual bone support.