Peri-implantitis is a plaque-associated inflammatory disease affecting the tissues surrounding a dental implant and characterized by inflammation of the peri-implant mucosa accompanied by progressive loss of supporting bone.
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Early identification depends on combining clinical examination, peri-implant probing, bleeding assessment, and standardized radiographic evaluation. No single clinical finding is sufficient to establish the diagnosis.
✅ Clinical Features of Peri-Implantitis
The clinical presentation is characterized primarily by signs of peri-implant inflammation and progressive changes in peri-implant tissue dimensions.
The principal findings include:
▪️ Bleeding on probing (BOP): A frequent indicator of peri-implant inflammation. Bleeding occurring shortly after gentle probing is particularly relevant.
▪️ Suppuration: May be present and indicates an inflammatory lesion, although its absence does not exclude peri-implantitis.
▪️ Increased probing depth (PD): Increasing PD compared with measurements obtained after prosthetic reconstruction is an important diagnostic finding.
▪️ Mucosal swelling and erythema: Reflect soft-tissue inflammation around the implant.
▪️ Mucosal recession: May expose the implant surface and contribute to an increased measured probing depth.
▪️ Progressive loss of peri-implant support: Represents the fundamental pathological component distinguishing peri-implantitis from peri-implant mucositis.
▪️ Implant mobility: Generally represents advanced loss of osseointegration rather than an early diagnostic feature and should be distinguished from mobility caused by prosthetic or mechanical complications.
The 2017 World Workshop consensus describes peri-implantitis sites as exhibiting inflammation, bleeding and/or suppuration, increased probing depths and/or mucosal recession, together with radiographic bone loss.
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| Clinical Finding | Typical Finding | Diagnostic Significance |
|---|---|---|
| Bleeding on probing | Bleeding after gentle probing | Indicates peri-implant inflammation |
| Suppuration | Purulent exudate on probing | Supports the presence of active inflammation |
| Increased probing depth | Increase compared with baseline | Important indicator of disease progression |
| Erythema and swelling | Inflamed peri-implant mucosa | Supports peri-implant inflammation |
| Mucosal recession | Apical displacement of the mucosal margin | May accompany tissue breakdown and increase probing depth |
Radiographic assessment is essential because peri-implantitis is defined partly by progressive loss of supporting bone. The most important radiographic parameter is the change in marginal peri-implant bone level relative to an appropriate baseline examination.
1. Progressive Marginal Bone Loss
The principal radiographic feature is bone loss around the implant beyond the expected initial remodeling.
A baseline radiograph obtained after completion of the implant-supported prosthesis provides an important reference for subsequent comparisons. When previous radiographs are unavailable, the 2018 diagnostic consensus proposed that a radiographic bone level ≥3 mm, combined with BOP and probing depth ≥6 mm, is indicative of peri-implantitis.
2. Vertical and Horizontal Bone Loss
Radiographic bone destruction may present as:
▪️ Horizontal or crestal bone loss
▪️ Vertical/intrabony defects
▪️ Circumferential bone defects
Peri-implantitis lesions may have complex three-dimensional configurations that are not completely represented by conventional two-dimensional imaging.
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Comparison of standardized radiographs over time is particularly valuable. Reproducible imaging geometry facilitates detection of relatively small changes in the peri-implant bone contour and level. Current radiological reviews continue to consider intraoral radiography the standard approach for routine assessment and follow-up, while CBCT is reserved for selected clinical situations.
4. CBCT Findings
Cone-beam computed tomography (CBCT) can provide additional information about the three-dimensional morphology of peri-implant defects, particularly buccal and lingual bone dimensions that may be poorly represented on periapical radiographs.
However, CBCT should not be considered a routine replacement for intraoral radiography. Metallic artifacts can obscure peri-implant structures, and the additional radiation exposure must be justified by the diagnostic question.
✅ Clinical and Radiographic Correlation
| Parameter | Peri-Implant Mucositis | Peri-Implantitis |
|---|---|---|
| Inflammation | Present | Present |
| Bleeding on probing | Usually present | Usually present |
| Probing depth | May increase because of inflammation | Increased compared with baseline or associated with bone loss |
| Radiographic bone loss | Absent beyond initial remodeling | Present and progressive |
| Supporting bone loss | No disease-related loss | Characteristic feature |
Radiographic bone loss around an implant should not automatically be interpreted as peri-implantitis. The clinician should consider:
▪️ Initial physiological bone remodeling
▪️ Peri-implant mucositis without progressive bone loss
▪️ Mechanical complications
▪️ Implant malposition
▪️ Excessive restorative contour or plaque-retentive prosthetic design
▪️ Endodontic lesions associated with adjacent teeth
▪️ Periapical implant lesions
▪️ Occlusal or prosthetic complications
Consequently, diagnosis requires clinical–radiographic correlation, rather than interpretation of an isolated radiographic finding.
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The diagnosis of peri-implantitis is fundamentally longitudinal. The most informative assessment combines inflammation, probing findings, and changes in radiographic bone level over time. The absence of a baseline radiograph makes diagnosis more difficult, which is why baseline probing and radiographic measurements after completion of the implant-supported prosthesis are recommended.
Current evidence also supports the continued use of standardized intraoral radiographs for routine monitoring. CBCT offers valuable three-dimensional information when the morphology or extent of a peri-implant defect cannot be adequately characterized with conventional imaging, but its routine use is not supported.
Emerging technologies, including artificial intelligence applied to radiographic images, may improve detection and quantification of peri-implant bone loss. However, current AI evidence is predominantly retrospective and internally validated, with substantial methodological limitations; these technologies should therefore be considered adjunctive rather than established diagnostic standards.
✍️ Conclusion
Peri-implantitis is characterized by peri-implant inflammation combined with progressive loss of supporting bone. The principal clinical findings are bleeding on probing, increased probing depth, suppuration, mucosal inflammation, and, in some cases, recession. The principal radiographic finding is bone loss beyond the initial remodeling phase.
Accurate diagnosis requires standardized clinical and radiographic assessment, preferably supported by baseline records. Intraoral radiography remains central to routine monitoring, whereas CBCT should be used selectively when three-dimensional information is clinically necessary.
🎯 Clinical Recommendations
▪️ Establish baseline probing depths and standardized intraoral radiographs after completion of the implant-supported prosthesis.
▪️ Compare subsequent examinations with baseline measurements rather than relying exclusively on absolute probing-depth values.
▪️ Interpret bleeding on probing together with radiographic bone changes; neither finding should be considered in isolation.
▪️ When previous radiographs are unavailable, use the established diagnostic combination of bone level ≥3 mm, probing depth ≥6 mm, and bleeding on probing as a clinical reference.
▪️ Reserve CBCT for cases in which conventional radiography does not adequately characterize the suspected defect, particularly when three-dimensional morphology will influence diagnosis or treatment planning.
▪️ Distinguish disease-associated bone loss from initial remodeling, mechanical complications, and other peri-implant or adjacent-tooth pathology.
▪️ Document clinical and radiographic findings longitudinally to identify progressive disease as early as possible.
📚 References
✔ Berglundh, T., Armitage, G., Araujo, M. G., Avila-Ortiz, G., Blanco, J., Camargo, P. M., Chen, S., Cochran, D., Derks, J., Figuero, E., Hämmerle, C. H. F., Heitz-Mayfield, L. J. A., Huynh-Ba, G., Iacono, V., Koo, K.-T., Lambert, F., McCauley, L., Quirynen, M., Renvert, S., Salvi, G. E., Schwarz, F., Tarnow, D., Tomasi, C., Wang, H.-L., & Zitzmann, N. (2018). Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Journal of Clinical Periodontology, 45(Suppl. 20), S286–S291. https://doi.org/10.1111/jcpe.12957
✔ Renvert, S., Hirooka, H., Polyzois, I., Kelekis-Cholakis, A., Wang, H.-L., & Working Group 3. (2018). Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants: Consensus report of working group 3. Journal of Clinical Periodontology, 45(Suppl. 20), S313–S318. https://doi.org/10.1111/jcpe.12957
✔ Heitz-Mayfield, L. J. A., Salvi, G. E., Mombelli, A., Faddy, M., & Lang, N. P. (2018). Peri-implant mucositis and peri-implantitis: Case definitions and diagnostic considerations. Journal of Clinical Periodontology, 45(Suppl. 20), S246–S252. https://doi.org/10.1111/jcpe.12956
✔ Schwarz, F., Derks, J., Monje, A., & Wang, H.-L. (2018). Peri-implantitis. Journal of Clinical Periodontology, 45(Suppl. 20), S246–S266. https://doi.org/10.1111/jcpe.12954
✔ Wismeijer, D., et al. (2024). Radiographic assessment of the peri-implant site. Periodontology 2000. https://doi.org/10.1111/prd.12577
✔ Jacobs, R., Vranckx, M., Vanderstuyft, T., Quirynen, M., & Salmon, B. (2018). CBCT vs other imaging modalities to assess peri-implant bone and diagnose complications: A systematic review. European Journal of Oral Implantology, 11(Suppl. 1), 77–92.
✔ Herrera, D., Berglundh, T., Schwarz, F., Chapple, I., Jepsen, S., Sculean, A., Kebschull, M., Papapanou, P. N., Tonetti, M. S., & Sanz, M. (2023). Prevention and treatment of peri-implant diseases—The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology, 50(Suppl. 26), 4–76. https://doi.org/10.1111/jcpe.13823
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