Gum care around implants: preventing peri-implant mucositis and peri-implantitis

Two diseases, one origin

Around an implant, the gum (called the peri-implant mucosa) is not attached to the surface as it is to a tooth: it rests against it as a cuff of tissue, without a ligament. This difference makes it less well defended against bacterial plaque.

Peri-implant mucositis is inflammation of this mucosa, without bone loss. Its main sign is bleeding when the depth of the groove around the implant is gently measured. It is reversible: signs of inflammation may take more than three weeks to resolve once plaque control is restored ^[1].

Peri-implantitis combines this inflammation with progressive loss of the bone that supports the implant. According to the 2018 international consensus, it progresses in a non-linear, accelerating pattern and appears to advance faster than periodontitis ^[1]. When no baseline measurements are available, diagnosis is based on bleeding or pus when the pockets are measured, a pocket depth of 6 mm or more, and a bone level 3 mm or more below the highest point of the part of the implant placed in the bone ^[1].

Common complications

The systematic review by Derks and Tomasi (2015), cited in the 2023 European guideline, estimated prevalence at about 43% of patients for mucositis and 22% for peri-implantitis ^[2][3]. These figures should be read with caution: the studies used different definitions, and the confidence interval was wide (14 to 30% for peri-implantitis). They nonetheless show that this is a common problem, not a rarity.

Who is most at risk?

The 2018 consensus distinguishes factors whose role is well established from others for which the evidence is still insufficient ^[1]:

For smoking and diabetes, “inconclusive” does not mean “no effect”: studies disagree or are lacking. The 2023 guideline lists smoking among factors associated with mucositis, and reports lower rates of peri-implantitis in people with well-controlled diabetes than in those with poor control ^[3]. Stopping smoking and controlling diabetes therefore remain sensible measures. Other elements matter too: the shape of the crown, which must let interdental brushes through, and the position of the implant ^[3].

What the EFP recommended in 2023: prevention first

The 2023 European S3 guideline on peri-implant diseases gives prevention a central place ^[3]. Among its strongest recommendations:

• Before the implant: treat gingivitis or periodontitis to stability (pockets of 4 mm or less, without bleeding) and follow a maintenance programme before placement.
• At the planning stage: allow enough space between the implant and neighbouring teeth, a suitable placement depth and a prosthesis that gives access to oral hygiene aids.
• After placement: measure pocket depth around the implant after fitting the prosthesis and take a baseline X-ray once bone remodelling is complete, then repeat these measurements at every check-up.
• Day to day: receive individually tailored oral hygiene instructions.
• Long term: attend regular supportive peri-implant care, even when everything is fine.

The guideline does not set an interval valid for every healthy patient: it is tailored to risk. A 2016 meta-analysis, based on observational studies, likewise urged caution in interpreting its results and personalising the schedule ^[4]. After treatment of peri-implantitis, the 2023 guideline suggests closer follow-up, then individually tailored ^[3]. In practice, the frequency is set at the practice according to your risk, and this follow-up is part of periodontal maintenance visits, which check teeth and implants at the same appointment.

Daily care around implants and bridges: interdental brushes, floss and water flosser

Plaque builds up on implants just as it does on teeth, and the most exposed area is the junction between the crown and the gum, often harder to reach than around a natural tooth. Cleaning relies on the same tools, with a few adjustments:

• Toothbrush, soft, manual or electric, twice a day, angling the bristles towards the junction between crown and gum, without pressing hard.
• Interdental brushes every day, sized for each space: the brush should enter with slight resistance, without forcing; one that is too thin does not clean, one that is too thick injures the gum. A coated wire avoids metal contact with the implant. Pass it straight through, with a few back-and-forth strokes, and replace it as soon as the bristles splay.
• Floss in spaces too narrow for a brush; for implant bridges, floss with a stiff threader passed under the pontic, or an angled brush.
• Water flosser: the jet dislodges debris and completes cleaning, especially under a bridge, but it does not replace the friction of a brush, which alone can disrupt plaque.
• If the gum is very thin or painful when brushing, mention it: thickening the mucosa can sometimes be considered ^[3].

Warning signs

Peri-implantitis is usually painless at first, like periodontitis. That is why its early, discreet signs are worth knowing:

• red, swollen gum, or gum that bleeds when brushing or when passing the interdental brush around the implant;
• persistent bad taste or bad breath, pus on pressing the gum;
• gum receding to reveal the metal collar of the implant;
• a feeling of discomfort or pressure around the implant, food catching more than before;
• a crown that moves: this is often a loosened screw, to be distinguished from mobility of the implant itself, which indicates advanced loss of anchorage.

Do not wait for your next appointment if one of these signs appears. Mucositis caught at this stage is treated simply; peri-implantitis detected early, through pocket measurements and an X-ray compared with the baseline, is treated with better prospects than an advanced form.

When disease is established: treatment

Mucositis. Recommended treatment combines professional cleaning of the implant and prosthesis with effective plaque control at home ^[3]. A short course of antiseptic mouthwash may be considered. However, the guideline suggests not adding air-polishing or a diode laser to professional cleaning, does not suggest photodynamic therapy and does not recommend local or systemic antibiotics.

Peri-implantitis. Treatment starts with a non-surgical phase; if inflammation and pockets persist, surgery allows the implant surface to be cleaned under direct vision and, depending on the shape of the defect, part of the bone to be rebuilt ^[3]. The guideline does not suggest using lasers, as an adjunct or alone, nor photodynamic therapy, and does not recommend routine systemic antibiotics. Lasers are discussed in detail in the article Lasers: what does the evidence say?

Before and after the implant: where this care fits

Prevention starts before placement. In someone who has had periodontitis, an implant is considered only once the disease has been treated and stabilised and follow-up is already in place: the preconditions and the course of treatment are described on the page Dental implants and bone surgery. After placement, the daily care described here and periodontal maintenance visits, during which implants are measured, cleaned with instruments that do not damage their surface and compared with baseline values, form a whole: one does not replace the other.

At Dr Hazout's practice in Levallois-Perret, this follow-up is the same for implants placed there and for those placed elsewhere; bringing the baseline X-ray and measurements, when you have them, makes it possible to judge the progression from the first visit.

Frequently asked questions