What is peri-implant disease, and what are its stages?
Like the tissues around natural teeth, the gum and bone around an implant can become inflamed because of bacterial plaque. The clinical guideline published in 2023 by the European Federation of Periodontology (EFP) points out that an implant surface does not renew itself as natural tissues do and that plaque can build up on it, so the implant itself should be regarded as a risk factor.
The inflammation has two stages:
- Peri-implant mucositis: The inflammation is limited to the gum around the implant, and there is no bone loss. According to the EFP’s guidance for clinicians, it can resolve once plaque control is re-established.
- Peri-implantitis: The inflammation spreads deeper and the bone supporting the implant is lost. The EFP guideline describes this damage as irreversible and notes that, if the disease progresses, the implant and its restoration are likely to be lost.
According to the EFP, mucositis is assumed to come before peri-implantitis, and it may progress to peri-implantitis, especially without regular maintenance care. The American Academy of Periodontology (AAP) also describes mucositis as the usual forerunner of peri-implantitis. This article focuses on how the problem is recognised and how it can be prevented.
How common is inflammation around implants?
It is not rare. According to a systematic review of 11 studies cited in the EFP guideline (Derks and Tomasi, 2015), about 43% of people with implants had peri-implant mucositis and 22% had peri-implantitis. Another review of 47 studies found figures of about 47% and 20%.
These figures are calculated per person, not per implant, so they do not mean that every implant has this chance of becoming diseased. The studies also differ in how they define the disease, how long they followed patients and which patients they included. Even so, the numbers show why everyone with implants should know about this condition and keep up with check-ups.
Which signs suggest inflammation around an implant?
According to the EFP’s patient information, these signs may point to inflammation around an implant:
- gums around the implant that bleed easily when you brush or clean between your teeth
- swelling of the gum
- bad breath or a bad taste in your mouth
- an implant, or the bridge or denture on it, that feels loose
The AAP lists red or tender gums and bleeding when brushing; the Oral Health Foundation lists red, sore or swollen gums, bleeding around the implant and infection. According to the EFP, it is not always easy to notice these changes yourself, which is one reason why check-ups matter even when you have no symptoms. If you notice signs of inflammation around an implant, the EFP advises making an appointment with your dentist as soon as possible.
How does a dentist diagnose it?
The diagnosis is made by examination and X-ray. According to the EFP’s guidance for clinicians, the dentist gently runs a thin, graduated instrument (a probe) into the gum pocket around the implant to check for bleeding or pus and to measure the pocket depth; an X-ray shows the level of the bone supporting the implant.
| Condition | Examination finding | Bone |
|---|---|---|
| Healthy | No bleeding or pus on gentle probing, no increase in pocket depth | No bone loss |
| Peri-implant mucositis | Bleeding and/or pus on gentle probing | No bone loss |
| Peri-implantitis | Bleeding and/or pus, with pocket depth increased compared with earlier examinations | Bone loss beyond the changes of the initial healing period |
This is why comparison with earlier records matters. The EFP guidance recommends taking a baseline X-ray and probing measurements once the implant restoration is complete, and the 2023 guideline recommends baseline probing within three months of the restoration being fitted, with probing repeated at every check-up. If there are no earlier records, the EFP guidance considers peri-implantitis likely when there is bleeding or pus together with pocket depths of 6 mm or more, and the bone on the X-ray is at least 3 mm below the top of the part of the implant that sits in the bone.
What increases the risk?
According to the EFP’s guidance, the strongest evidence is for a history of severe gum disease (periodontitis), and for poor plaque control combined with not attending regular maintenance. The same guidance considers the evidence on smoking and diabetes as risk factors for peri-implantitis inconclusive; however, the 2023 guideline lists smoking among the factors associated with mucositis, and the AAP includes both smoking and diabetes among the risk factors. Leeds Teaching Hospitals NHS Trust also lists poorly controlled diabetes and previous radiotherapy to the jaws among the factors that increase the risk of implant problems.
The EFP’s 2023 guideline treats prevention as a process that starts when implants are being planned:
| Stage | What the guideline recommends |
|---|---|
| Before implants | Treating gum disease and bringing it under control; stopping or reducing smoking, including e-cigarettes; improving blood sugar control in diabetes; improving oral hygiene; addressing habits such as clenching and grinding |
| Planning and design of the restoration | Placing the implant in a position that allows cleaning; designing the restoration so that the patient’s cleaning aids and the dentist’s measuring and cleaning instruments can reach the implant, without excessive bulk; choosing a screw-retained restoration where appropriate |
| While the implant is in place | Regular supportive care appointments and home care adapted to the design of the restoration |
How do you clean around implants at home?
According to the Oral Health Foundation, cleaning implants is similar to cleaning natural teeth:
- Brush with fluoride toothpaste for two minutes at least twice a day, once last thing at night.
- Clean around every implant each day with interdental brushes. The AAP and Leeds Teaching Hospitals also recommend floss.
- If you have a removable implant denture, Leeds Teaching Hospitals advise taking it out at night and to clean the implants; fixed restorations are cleaned in the mouth.
- If you smoke, get support to stop.
The EFP guideline stresses that home care should be adapted to the design of the implant restoration. The Oral Health Foundation also says your dental team can show you how to clean around your implant; the size of interdental brush and the other aids you need depend on your restoration. If the gum around an implant bleeds when you clean it, do not stop cleaning: according to the EFP, mucositis can resolve once plaque control is re-established.
Why do regular check-ups matter so much?
The EFP’s 2023 guideline recommends regular supportive care for people with implants, including while the tissues around them are healthy. This care includes professional removal of plaque above and below the gum line, a review of your oral hygiene and early detection of problems. According to the EFP guidance, mucositis may progress to peri-implantitis, especially without regular maintenance care.
Early detection also matters because of the way the disease develops: according to the EFP guidance, peri-implantitis progresses faster than periodontitis around natural teeth, and in a non-linear, accelerating pattern. The AAP also stresses that implants should be monitored regularly as part of a comprehensive gum examination.
The check-up interval is not the same for everyone. The studies behind the EFP guideline used different intervals, from tailored ones to every three months or up to every 12 months. Your dentist decides the right interval for you based on your history of gum disease, risks such as smoking and diabetes, and the type of restoration you have.
If your implants were placed abroad, your local dentist can carry out these check-ups. Because comparison with earlier findings matters, ask for copies of your X-rays and keep the details of your implant to hand for your dentist at home. Our page on aftercare and follow-up explains how follow-up works after you return.
How is inflammation around implants treated?
Treatment depends on the stage. According to the EFP’s 2023 guideline:
- In mucositis, the aim is to remove the plaque build-up: the area is cleaned professionally and home care is improved. The result is assessed after two to three months, and treatment is repeated if the desired healing has not been reached.
- In peri-implantitis, the first step is to decide whether the implant can be treated. If it can, the first stage is non-surgical deep cleaning; the result is then reassessed, and surgical treatment follows if the goals have not been met.
According to the AAP, mucositis is reversible when caught early, while peri-implantitis usually requires surgical treatment. The EFP’s patient information notes that peri-implantitis is usually much more difficult to treat than gum disease around natural teeth; an implant can lose its anchorage in the bone and may need to be replaced, and additional surgery may be needed to restore the lost bone. Which treatment is suitable is decided at the examination.
How is implant health followed up at Rönesans?
Implant treatment is one of our areas of treatment, and follow-up after treatment runs through a defined process. The gum and bone around your implants are monitored at check-up appointments, and the dentist decides at the examination which imaging is needed. Our practice has a device that removes plaque with a spray of air, water and fine powder; which cleaning method is used around your implants is decided by the dentist after the examination.
After treatment, you receive an implant card with the batch details of your implant. Years later, if you see another dentist, for example at home, this card helps them identify your implant correctly. If inflammation is found around an implant, the treatment options are assessed at the examination. You receive a written treatment and cost plan showing the procedures and the unit and total costs, and you know from the start which dentist will follow your treatment. Costs are confirmed after the examination, based on your treatment plan.
If you notice bleeding, swelling or looseness around an implant, send us photos on WhatsApp or write to us through our contact form; during opening hours, we answer messages in English and German within 15 minutes. Photos cannot replace an examination, so you may still be advised to see a dentist in person. You can read about the stages of implant treatment on our page on dental implants in Türkiye and about fixed teeth for a whole jaw on our page on full-arch implants.