5 Common Oral Infections in Dentistry: Signs and Treatment

Oral infections encompass a heterogeneous group of bacterial, fungal, and viral diseases affecting the teeth, periodontal tissues, oral mucosa, and surrounding structures.

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Their clinical presentation ranges from localized inflammation to infections capable of spreading into deep facial and cervical spaces.

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Accurate diagnosis is essential because treatment depends on the etiology, anatomical site, severity, and systemic involvement. In odontogenic bacterial infections, definitive dental treatment and elimination of the source should generally take priority over systemic antibiotics.
The following five conditions represent clinically important infections frequently encountered in dental practice.

1. Periodontitis
Definition
Periodontitis is a chronic inflammatory disease associated with dysbiotic subgingival biofilms that results in progressive destruction of the tooth-supporting tissues. Clinical features include periodontal pocketing, clinical attachment loss, and alveolar bone loss.

Signs
▪️ Gingival inflammation and bleeding on probing
▪️ Periodontal pockets
▪️ Clinical attachment loss
▪️ Gingival recession
▪️ Tooth mobility in advanced disease
▪️ Radiographic alveolar bone loss
▪️ Tooth migration in severe cases

Symptoms
Patients may be asymptomatic during the early stages. Advanced disease may produce gingival bleeding, halitosis, discomfort during mastication, tooth mobility, or sensitivity.

Treatment
Treatment is based on disease stage and risk profile. It generally includes:
▪️ Patient education and oral-hygiene optimization
▪️ Supragingival and subgingival biofilm control
▪️ Professional periodontal instrumentation
▪️ Risk-factor control
▪️ Periodontal surgery when indicated
▪️ Long-term supportive periodontal care
Systemic antibiotics are not routinely indicated for conventional periodontitis and should be reserved for selected clinical situations.

Prevention
▪️ Maintain effective daily plaque control with toothbrushing and interdental cleaning.
▪️ Undergo regular periodontal assessment based on individual risk.
▪️ Avoid tobacco use and address modifiable periodontal risk factors.
▪️ Maintain appropriate supportive periodontal care after active treatment.

2. Odontogenic Abscess
Definition
An odontogenic abscess is a localized collection of purulent material resulting from a bacterial infection originating from the dental pulp, periapical tissues, or periodontal structures.

Signs
▪️ Localized swelling
▪️ Fluctuance or purulent drainage
▪️ Tenderness to percussion
▪️ Intraoral or extraoral edema
▪️ Local lymphadenopathy in some cases
▪️ Tooth discoloration or extensive caries when pulpal necrosis is present

Symptoms
Common symptoms include spontaneous dental pain, pain on biting, swelling, tenderness, and a sensation of pressure. Fever, malaise, and regional lymphadenopathy may indicate systemic involvement.

Treatment
Management should focus on eliminating the source of infection and establishing drainage when indicated. Depending on the diagnosis, treatment may include:
▪️ Pulpotomy or pulpectomy in appropriate cases
▪️ Nonsurgical root canal treatment
▪️ Tooth extraction when the tooth cannot be predictably restored
▪️ Incision and drainage when clinically indicated
▪️ Analgesics for pain control
Systemic antibiotics are generally unnecessary for localized infections in immunocompetent patients when definitive dental treatment is available.Antibiotics become appropriate when systemic involvement or significant spreading infection is present.

Prevention
▪️ Maintain effective oral hygiene and plaque control.
▪️ Prevent and treat dental caries at an early stage.
▪️ Attend regular dental examinations to identify caries, pulpal disease, and defective restorations.
▪️ Complete indicated restorative or endodontic treatment before infection progresses.

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3. Periodontal Abscess
Definition
A periodontal abscess is an acute localized accumulation of pus within the periodontal tissues, commonly associated with a periodontal pocket and rapid localized tissue destruction.

Signs
▪️ Localized gingival swelling
▪️ Purulent exudate
▪️ Deep periodontal pocket
▪️ Tooth mobility
▪️ Gingival erythema
▪️ Localized elevation of the gingival margin

Symptoms
Patients may report localized pain, tenderness during biting, a feeling of tooth elevation, and discomfort during chewing.

Treatment
Treatment generally involves:
▪️ Drainage through the periodontal pocket or incision when necessary
▪️ Thorough periodontal debridement
▪️ Removal of local contributing factors
▪️ Occlusal assessment when indicated
▪️ Periodontal therapy after the acute phase
Systemic antibiotics should not replace local treatment and are generally reserved for systemic manifestations, spreading infection, or specific medically compromised situations.

Prevention
▪️ Maintain adequate periodontal biofilm control.
▪️ Treat periodontal pockets and active periodontal disease appropriately.
▪️ Attend supportive periodontal therapy at intervals determined by individual risk.
▪️ Monitor sites with previous periodontal abscesses for recurrent inflammation or pocketing.

4. Pericoronitis
Definition
Pericoronitis is an inflammatory and infectious condition of the soft tissues surrounding the crown of a partially erupted tooth, most frequently associated with mandibular third molars.

Signs
▪️ Inflamed operculum
▪️ Localized edema and erythema
▪️ Purulent discharge
▪️ Food accumulation beneath the operculum
▪️ Tender regional lymph nodes in some cases
▪️ Limited mouth opening in more severe infections

Symptoms
Typical symptoms include localized pain, swelling, unpleasant taste or odor, difficulty chewing, and sometimes trismus or dysphagia.

Treatment
Initial management focuses on controlling the local infection:
▪️ Irrigation and debridement of the affected area
▪️ Removal of local irritants and impacted debris
▪️ Appropriate analgesia
▪️ Antiseptic therapy when indicated
▪️ Evaluation for extraction or other definitive management of the associated tooth
Systemic antibiotics should be considered primarily when there is spreading infection, systemic involvement, or significant trismus rather than uncomplicated localized inflammation.

Prevention
▪️ Maintain meticulous oral hygiene around partially erupted third molars.
▪️ Remove food debris and plaque from the operculum region.
▪️ Monitor partially erupted third molars clinically and radiographically when indicated.
▪️ Consider definitive management when recurrent pericoronitis is associated with a tooth with poor eruption potential.

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5. Oral Candidiasis
Definition
Oral candidiasis is a fungal infection of the oral mucosa, most commonly associated with Candida albicans. Predisposing factors include immunosuppression, antibiotic exposure, corticosteroid use, xerostomia, and poorly controlled systemic disease.

Signs
▪️ Removable white plaques in pseudomembranous candidiasis
▪️ Erythematous mucosa after plaque removal
▪️ Atrophic or erythematous lesions
▪️ Angular involvement in some patients
▪️ Chronic mucosal changes in persistent disease

Symptoms
Patients may experience oral burning, soreness, altered taste, taste loss, or discomfort when eating spicy or acidic foods. Some cases are asymptomatic.

Treatment
Management includes:
▪️ Identification and correction of predisposing factors
▪️ Improved oral hygiene and denture hygiene
▪️ Topical antifungal therapy for mild disease
▪️ Systemic antifungal therapy for moderate-to-severe disease or selected refractory cases
Persistent or recurrent candidiasis should prompt evaluation for underlying predisposing conditions.

Prevention
▪️ Maintain good oral and denture hygiene.
▪️ Remove and clean dentures regularly; avoid wearing them continuously, particularly during sleep.
▪️ Rinse the mouth after using inhaled corticosteroids.
▪️ Minimize unnecessary antibiotic exposure when clinically appropriate.
▪️ Address xerostomia and other predisposing factors when identified.

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✅ Clinical Comparison

Infection	Primary Cause	Key Signs	Main Treatment
Periodontitis	Dysbiotic periodontal biofilm and host inflammatory response	Pocketing, bleeding, attachment and bone loss	Periodontal therapy and supportive care
Odontogenic Abscess	Bacterial infection of pulpal/periapical tissues	Pain, swelling, tenderness, purulence	Drainage and definitive dental treatment
Periodontal Abscess	Infection associated with periodontal pocketing	Localized swelling, pus, deep pocket, pain	Drainage and periodontal debridement
Pericoronitis	Infection/inflammation around a partially erupted tooth	Operculum inflammation, pain, swelling, possible trismus	Local debridement and definitive tooth management
Oral Candidiasis	Overgrowth of Candida species	White plaques, erythema, burning, altered taste	Antifungal therapy and correction of predisposing factors

✅ Prevention of Common Oral Infections
Preventive strategies should focus on biofilm control, early detection, management of predisposing factors, and regular dental care. Prevention differs according to the infectious process and should be individualized according to the patient's oral and systemic risk profile.

Infection	Key Preventive Measures
Periodontitis	Daily plaque control, interdental cleaning, periodontal monitoring, tobacco cessation, and supportive periodontal care.
Odontogenic Abscess	Caries prevention, early restorative care, regular examinations, and timely endodontic treatment when indicated.
Periodontal Abscess	Periodontal disease control, biofilm management, pocket monitoring, and maintenance therapy.
Pericoronitis	Oral hygiene around partially erupted teeth, debris removal, clinical monitoring, and definitive management when recurrent.
Oral Candidiasis	Denture hygiene, appropriate corticosteroid use, avoidance of unnecessary antibiotics, and management of predisposing factors.

💬 Discussion
Although these conditions are grouped under the broad concept of oral infection, their biological mechanisms and therapeutic approaches differ substantially. Periodontitis is a chronic biofilm-associated inflammatory disease, whereas odontogenic and periodontal abscesses are typically acute bacterial infections requiring control of the local source.
A clinically important principle is that antimicrobial therapy should not substitute for definitive dental treatment. For localized pulpal and periapical infections, current evidence-based guidance emphasizes procedures such as root canal treatment, extraction, or drainage rather than routine antibiotic prescribing. Antibiotics are principally indicated when systemic involvement or clinically significant spread is present.
Fungal and viral infections require a different therapeutic approach. Oral candidiasis is managed with antifungal therapy and correction of predisposing factors, whereas herpes labialis, when treated, responds to antiviral therapy initiated early in the course of recurrence.
Therefore, diagnosis should integrate clinical examination, periodontal assessment, pulpal and periapical testing, radiographic findings, and evaluation for systemic involvement rather than relying exclusively on the presence of pain or swelling.

✍️ Conclusion
The five conditions reviewed—periodontitis, odontogenic abscess, periodontal abscess, pericoronitis, and oral candidiasis—represent important infectious or infection-associated conditions encountered in dental practice. Their management requires accurate diagnosis, control of the underlying cause, and treatment according to the specific pathology.
Prevention remains fundamental and relies on effective oral-hygiene measures, early detection and treatment of dental and periodontal disease, appropriate management of predisposing factors, and regular professional follow-up. In acute infections, source control should remain the primary therapeutic objective, while systemic antimicrobial therapy should be reserved for appropriate clinical indications.

🎯 Clinical Recommendations
▪️ Establish the anatomical and etiological source of infection before prescribing antimicrobial therapy.
▪️ Prioritize source control, including drainage, periodontal debridement, endodontic treatment, or extraction when indicated.
▪️ Assess every acute infection for fever, malaise, facial/cervical swelling, dysphagia, dyspnea, or progressive trismus.
▪️ Avoid routine systemic antibiotics for localized odontogenic infections when adequate definitive dental treatment can be provided.
▪️ Reassess patients with persistent, recurrent, or atypical oral infections for underlying systemic, immunological, medication-related, or local predisposing factors.
▪️ Refer urgently when infection threatens the airway, extends into deep facial or cervical spaces, or is associated with systemic deterioration.

📚 References

✔ Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Beglundh, T., Sculean, A., Tonetti, M. S., & EFP Workshop Participants and Methodological Consultants. (2020). Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. *Journal of Clinical Periodontology, 47*(Suppl. 22), 4–60. https://doi.org/10.1111/jcpe.13290
✔ Jevon, P., Abdelrahman, A., & Pigadas, N. (2020). Management of odontogenic infections and sepsis: An update. *British Dental Journal, 229*(6), 363–370. https://doi.org/10.1038/s41415-020-2114-5
✔ Pappas, P. G., Kauffman, C. A., Andes, D. R., Clancy, C. J., Marr, K. A., Ostrosky-Zeichner, L., Reboli, A. C., Schuster, M. G., Vazquez, J. A., Walsh, T. J., Zaoutis, T. E., & Sobel, J. D. (2016). Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. *Clinical Infectious Diseases, 62*(4), e1–e50. https://doi.org/10.1093/cid/civ933
✔ Du, R., Ba, K., Yang, Y., Zhao, Y., & Lin, Y. (2024). Efficacy of ornidazole for pericoronitis: A meta-analysis and systematic review. *Archives of Medical Science*. https://doi.org/10.5114/aoms/171907
✔ Chen, F., Xu, H., Liu, J., Cui, Y., Luo, X., Zhou, Y., Chen, Q., & Jiang, L. (2017). Efficacy and safety of nucleoside antiviral drugs for treatment of recurrent herpes labialis: A systematic review and meta-analysis. *Journal of Oral Pathology & Medicine, 46*(8), 561–568. https://doi.org/10.1111/jop.12534
✔ American Dental Association. (2019). *Antibiotics for dental pain and swelling guideline*. American Dental Association.

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Amoxicillin + Metronidazole in Dentistry: When to Use It

Amoxicillin + metronidazole is a combination of systemic antibiotics used in selected dental infections because the two agents provide complementary antimicrobial activity.

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Amoxicillin primarily targets susceptible aerobic and facultative bacteria, whereas metronidazole provides strong activity against anaerobic microorganisms.

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However, the combination should not be prescribed routinely for dental pain, localized dental infections, or uncomplicated periodontal disease.
Current antibiotic-stewardship recommendations emphasize definitive dental treatment, including drainage, endodontic treatment, extraction, or periodontal instrumentation, as the primary intervention whenever appropriate.

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✅ When Is Amoxicillin + Metronidazole Used in Dentistry?
The combination has two main clinical contexts: selected severe odontogenic infections and specific periodontal cases in which systemic antibiotics are used as an adjunct to mechanical periodontal therapy.

1. Severe or spreading odontogenic infections
Systemic antibiotics may be appropriate when an odontogenic infection demonstrates spreading infection or systemic involvement, particularly when there is fever, malaise, progressive swelling, lymphadenopathy, or involvement of multiple anatomical spaces.
In these situations, antibiotics must complement, rather than replace, source control. Incision and drainage, extraction, or endodontic treatment should be performed whenever indicated.
For uncomplicated localized acute apical abscesses in immunocompetent adults, antibiotics are generally unnecessary when definitive dental treatment can be provided promptly.

2. Selected patients with advanced periodontitis
The combination has been studied extensively as an adjunct to subgingival instrumentation in patients with severe or rapidly progressing periodontitis.
The strongest evidence concerns patients with generalized Stage III periodontitis, particularly younger patients and cases with deep periodontal pockets. The European Federation of Periodontology does not recommend routine systemic antibiotics for periodontitis but states that specific systemic antibiotics may be considered in selected patient categories.
Clinical trials have demonstrated additional reductions in probing depth and improvements in clinical attachment when amoxicillin + metronidazole is combined with mechanical periodontal treatment in appropriately selected patients.

3. Periodontal infections with a substantial anaerobic component
The rationale for combining these drugs is particularly relevant when the periodontal microbiota includes substantial populations of anaerobic periodontal pathogens. Metronidazole has potent activity against anaerobic bacteria, while amoxicillin provides complementary activity against susceptible organisms.
This does not mean that microbiological testing is required before every prescription. Rather, the combination should be considered within an overall periodontal diagnosis and treatment plan rather than simply because a patient has bleeding gums or periodontal pockets.

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✅ When Should It Not Be Used?
Amoxicillin + metronidazole should generally not be used for:
▪️ Irreversible pulpitis without systemic involvement
▪️ Symptomatic apical periodontitis without systemic involvement
▪️ Localized acute apical abscess when adequate drainage or definitive dental treatment is available
▪️ Routine treatment of uncomplicated gingivitis
▪️ Routine treatment of periodontitis
▪️ Dental pain alone
▪️ As a substitute for endodontic treatment, extraction, drainage, or periodontal instrumentation
The ADA guideline specifically recommends prioritizing definitive conservative dental treatment rather than antibiotics for most pulpal and periapical conditions.

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✅ Clinical Context and Antibiotic Rationale

Clinical Situation	Role of Amoxicillin + Metronidazole	Primary Management
Localized acute apical abscess	Usually not indicated if definitive treatment is immediately available	Drainage, endodontic treatment, or extraction
Odontogenic infection with systemic involvement	Systemic antibiotic therapy may be indicated; regimen depends on clinical circumstances and local guidance	Source control plus appropriate systemic therapy
Generalized Stage III/Grade C periodontitis	May be considered as an adjunct in selected patients	Subgingival instrumentation and comprehensive periodontal therapy
Routine gingivitis or uncomplicated periodontitis	Not routinely indicated	Biofilm control and appropriate periodontal treatment

✅ Dosage Considerations
The exact regimen should be determined according to the diagnosis, severity, patient factors, local antimicrobial guidelines, and antimicrobial stewardship principles.
In periodontal clinical trials, commonly investigated regimens have included amoxicillin 500 mg plus metronidazole 500 mg, three times daily, for either 3 or 7 days. A randomized clinical trial in Stage III/IV Grade C periodontitis found comparable clinical outcomes with 3 versus 7 days when the antibiotics were used adjunctively with subgingival instrumentation.
These research regimens should not be interpreted as a universal prescription protocol for all dental infections.

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✅ Important Safety Considerations
Before prescribing, clinicians should evaluate:

▪️ Penicillin allergy, including the type and severity of previous reactions.
▪️ Previous adverse reactions to metronidazole.
▪️ Significant hepatic or other relevant medical conditions.
▪️ Potential drug interactions.
▪️ Pregnancy or breastfeeding when clinically relevant.
▪️ Previous antibiotic exposure and risk of antimicrobial resistance.
▪️ The need for urgent referral in patients with rapidly spreading infection, airway compromise, dysphagia, systemic deterioration, or deep-space involvement.
Metronidazole also requires particular attention to medication counseling, including avoidance of alcohol during treatment and for the period recommended by current prescribing information.

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💬 Discussion
The combination of amoxicillin and metronidazole has a well-established evidence base as an adjunct in selected periodontal patients, particularly those with advanced disease and deep periodontal pockets. Randomized trials have demonstrated additional clinical benefits when systemic antibiotics are combined with thorough mechanical periodontal therapy.
Nevertheless, the magnitude of benefit must be balanced against adverse effects, antimicrobial resistance, and broader microbiome consequences. The EFP therefore recommends against routine systemic antibiotic use as an adjunct to periodontal debridement, while allowing consideration in selected patient categories.
For acute odontogenic infections, the clinical principle is different: antibiotics are primarily indicated when infection extends beyond the local site or produces systemic manifestations. The ADA emphasizes that antibiotics should not delay or substitute for definitive dental treatment.

🎯 Clinical Recommendations
▪️ Reserve amoxicillin + metronidazole for clearly defined clinical indications rather than routine dental infections.
▪️ In odontogenic infection, prioritize source control through drainage, endodontic treatment, or extraction.
▪️ Consider systemic antibiotic therapy in selected patients with advanced or rapidly progressing periodontitis, particularly when supported by the overall clinical presentation.
▪️ Avoid prescribing antibiotics solely for dental pain, localized infection, or routine periodontal disease.
▪️ Select the dose and duration according to current local guidelines and patient-specific risk factors.
▪️ Reassess patients who fail to improve; persistent or progressive infection may require microbiological assessment, treatment modification, specialist referral, or hospital management.
▪️ Use the narrowest appropriate antimicrobial regimen and the shortest effective duration to support antibiotic stewardship.

✍️ Conclusion
Amoxicillin + metronidazole in dentistry has a specific rather than universal role. Its principal evidence-supported periodontal application is as an adjunct to mechanical treatment in selected patients with advanced periodontitis, while systemic antibiotics may also be necessary in odontogenic infections with systemic or spreading features.
The key clinical principle is that antibiotics complement definitive dental treatment; they do not replace it. Appropriate patient selection is essential to maximize clinical benefit while minimizing adverse effects and antimicrobial resistance.

📚 References

✔ American Dental Association. (2019). Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. Journal of the American Dental Association, 150(11), 906–921.e12. https://doi.org/10.1016/j.adaj.2019.08.020
✔ Cosgarea, R., et al. (2022). Clinical, microbiological, and immunological effects of 3- or 7-day systemic antibiotics adjunctive to subgingival instrumentation in patients with aggressive (Stage III/IV Grade C) periodontitis: A randomized placebo-controlled clinical trial. Journal of Clinical Periodontology, 49(11), 1128–1140. https://doi.org/10.1111/jcpe.13676
✔ Guerrero, A., Griffiths, G. S., Nibali, L., Suvan, J., Moles, D. R., Laurell, L., & Tonetti, M. S. (2005). Adjunctive benefits of systemic amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: A randomized placebo-controlled clinical trial. Journal of Clinical Periodontology, 32(10), 1096–1107. https://doi.org/10.1111/j.1600-051X.2005.00814.x
✔ Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Beglundh, T., Sculean, A., Tonetti, M. S., & EFP Workshop Participants and Methodological Consultants. (2020). Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology, 47(Suppl. 22), 4–60. https://doi.org/10.1111/jcpe.13290
✔ Zúñiga-Loor, D., Parise-Vasco, J. M., & Montesinos-Guevara, C. (2024). Mechanical debridement combined with amoxicillin and metronidazole compared with mechanical debridement alone for the treatment of chronic periodontitis: An overview of systematic reviews. Dental and Medical Problems, 61(3), 439–446. https://doi.org/10.17219/dmp/158925

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Gingival Recession Treatment: Modern Treatment Options

Gingival recession is characterized by apical displacement of the gingival margin, resulting in exposure of the root surface. It may be associated with dentin hypersensitivity, root caries, non-carious cervical lesions, aesthetic concerns, and progressive loss of soft-tissue coverage.

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Current management is not based on a single treatment for every patient. The appropriate approach depends on the recession depth, interproximal attachment, gingival phenotype, periodontal status, root anatomy, symptoms, aesthetic expectations, and etiologic factors. The contemporary objective is to control modifiable risk factors and, when indicated, obtain stable root coverage.

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✅ What Is the Current Treatment for Gingival Recession?
Treatment can be divided into non-surgical management and periodontal plastic surgery.

Clinical Situation	Current Management
Mild recession without symptoms or progression	Risk-factor control and periodontal maintenance
Dentin hypersensitivity	Desensitizing agents and exposure control
Plaque-related inflammation	Professional periodontal therapy and optimized plaque control
Root caries or cervical lesion	Restorative management when indicated
Aesthetic concern or progressive recession	Periodontal plastic surgery
Localized recession suitable for root coverage	Coronally advanced flap ± connective tissue graft
Multiple adjacent recessions	Tunnel or coronally advanced techniques, usually with connective tissue graft
Limited donor tissue or avoidance of palatal surgery	Collagen or other soft-tissue substitutes may be considered

1. Non-Surgical Management
Not every gingival recession requires surgery. The initial approach should identify and control factors that may contribute to progression or symptoms.

Management may include:
▪️ Improvement of plaque control without traumatizing the marginal tissues.
▪️ Correction of inappropriate oral-hygiene practices when clinically relevant.
▪️ Management of periodontal inflammation or periodontitis.
▪️ Treatment of dentin hypersensitivity with appropriate desensitizing agents.
▪️ Evaluation and treatment of non-carious cervical lesions or root caries.
▪️ Periodic periodontal monitoring to determine whether the recession remains stable.
The evidence regarding traumatic toothbrushing as a direct cause of recession is not completely consistent. Therefore, clinicians should avoid attributing every recession solely to brushing technique and should evaluate the entire clinical context.

2. Connective Tissue Graft With a Coronally Advanced Flap
For a suitable localized gingival recession, the combination of a subepithelial connective tissue graft (CTG) and coronally advanced flap (CAF) remains one of the most predictable approaches for root coverage.
A systematic review and network meta-analysis involving 38 studies found that CTG + CAF ranked highest for mean root coverage, complete root coverage, and gain in keratinized tissue for single recession defects. The authors concluded that this combination can be considered the current gold-standard approach for these indications.

The technique is particularly valuable when the objectives include:
▪️ Root coverage
▪️ Increased gingival thickness
▪️ Increased keratinized tissue
▪️ Reduction of dentin hypersensitivity
▪️ Improvement of gingival aesthetics
▪️ Long-term soft-tissue stability

3. Tunnel Techniques
Tunnel procedures combined with a connective tissue graft are another important option, particularly for multiple adjacent recessions.
Evidence indicates that tunnel and coronally advanced flap approaches can provide comparable overall root-coverage outcomes in appropriately selected cases, although the optimal technique depends on defect morphology, tissue thickness, interdental anatomy, and operator expertise.

4. Collagen Matrices and Other Alternatives
When harvesting an autogenous graft is undesirable or contraindicated, xenogeneic collagen matrices, acellular dermal matrices, and other soft-tissue substitutes can be considered.
These materials may reduce the need for a palatal donor site and can reduce postoperative morbidity. However, current evidence generally continues to support autogenous connective tissue grafts as the most predictable option, particularly when maximum root coverage and soft-tissue augmentation are priorities.

5. Enamel Matrix Derivative
Enamel matrix derivative (EMD) may be used as an adjunct to selected root-coverage procedures. A systematic review and meta-analysis found a statistically significant improvement in root coverage when EMD was added to CAF + CTG, although the magnitude of the additional benefit was relatively modest.
Therefore, EMD should generally be regarded as an adjunct rather than a replacement for the fundamental surgical technique.

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✅ How Should the Recession Be Evaluated?
Modern diagnosis should consider the interproximal clinical attachment level, rather than relying exclusively on the traditional Miller classification.

The Cairo classification distinguishes:
▪️ RT1: recession without interproximal attachment loss.
▪️ RT2: interproximal attachment loss that is equal to or less than the buccal attachment loss.
▪️ RT3: interproximal attachment loss greater than the buccal attachment loss.
The amount of interproximal attachment is clinically important because it influences the predictability of complete root coverage.

A complete periodontal assessment should also consider:
▪️ Recession depth and width
▪️ Gingival phenotype
▪️ Keratinized tissue
▪️ Interproximal attachment
▪️ Root prominence
▪️ Tooth position
▪️ Periodontal inflammation
▪️ Presence of cervical lesions
▪️ Patient symptoms and aesthetic expectations

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✅ When Is Surgery Indicated?
Root-coverage surgery should be considered when the recession produces significant aesthetic concerns, persistent hypersensitivity, progressive tissue loss, root caries risk, or other clinically relevant problems that cannot be adequately managed with conservative measures.
However, surgery should not be performed simply because a recession is visible. Stable, asymptomatic recession without functional or aesthetic concerns may be managed conservatively with monitoring and risk-factor control.
Untreated recession can progress over time in some patients; therefore, periodic assessment is appropriate even when surgery is not initially indicated.

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💬 Discussion
The current evidence supports an individualized, defect-based approach to gingival recession. Conservative management remains appropriate for stable and asymptomatic defects, whereas surgical root coverage is indicated when symptoms, aesthetics, progression, or tissue-management objectives justify intervention.
For appropriately selected single recession defects, coronally advanced flap combined with a subepithelial connective tissue graft remains the most predictable reference treatment. Tunnel techniques provide an important alternative for multiple recessions, while collagen matrices and other substitutes can be considered when an autogenous graft is unsuitable or when reduced donor-site morbidity is prioritized.
The presence of a non-carious cervical lesion should also be identified before surgery because the altered cemento-enamel junction and root-surface anatomy can affect the predictability of root coverage and may require a combined restorative-periodontal approach.

✍️ Conclusion
The current treatment of gingival recession begins with accurate diagnosis and control of modifiable risk factors. Non-surgical management is appropriate for many stable defects, while periodontal plastic surgery is indicated when root coverage, symptom control, tissue augmentation, or aesthetic improvement is required.
For suitable localized defects, connective tissue grafting combined with a coronally advanced flap remains the most evidence-supported and predictable approach. Alternative techniques and biomaterials should be selected according to defect characteristics, patient preferences, donor-site considerations, and the clinician's surgical expertise.

🎯 Clinical Recommendations
1. Classify the recession and assess interproximal attachment before selecting a root-coverage technique.
2. Control periodontal inflammation and modifiable risk factors before surgery.
3. For predictable root coverage of appropriate localized defects, consider CAF + subepithelial connective tissue graft as the reference approach.
4. For multiple adjacent recessions, consider tunnel or coronally advanced techniques combined with soft-tissue grafting according to anatomy and operator expertise.
5. Consider collagen matrices or other substitutes when an autogenous donor site is undesirable or contraindicated, recognizing that clinical outcomes may differ from those obtained with CTG.
6. Evaluate non-carious cervical lesions before surgery and consider coordinated restorative-periodontal treatment when indicated.
7. Maintain long-term periodontal supportive care and clinical monitoring, even after successful root-coverage therapy.

📚 References

✔ Chambrone, L., Botelho, J., Machado, V., Mascarenhas, P., Mendes, J. J., & Avila-Ortiz, G. (2022). Does the subepithelial connective tissue graft in conjunction with a coronally advanced flap remain as the gold standard therapy for the treatment of single gingival recession defects? A systematic review and network meta-analysis. Journal of Periodontology, 93(9), 1336–1352. https://doi.org/10.1002/JPER.22-0167
✔ Chapple, I. L. C., Mealey, B. L., Van Dyke, T. E., Bartold, P. M., Dommisch, H., Eickholz, P., Geisinger, M. L., Genco, R. J., Glogauer, M., Goldstein, M., Griffin, T. J., Holmstrup, P., Johnson, G. K., Kapila, Y., Lang, N. P., Meyle, J., Murakami, S., Plemons, J., Romito, G. A., Shapira, L., Teughels, W., Trombelli, L., Walter, C., Wimmer, G., & Xenoudi, P. (2018). Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop. Journal of Clinical Periodontology, 45(Suppl. 20), S68–S77. https://doi.org/10.1111/jcpe.12940
✔ Cairo, F., Nieri, M., Pagliaro, U. (2008). Treatment of gingival recession with coronally advanced flap procedures: A systematic review. Journal of Clinical Periodontology, 35(8 Suppl.), 136–162. https://doi.org/10.1111/j.1600-051X.2008.01267.x
✔ Gennai, S., Ben Guiza, Z., Orsolini, C., & Gosset, M. (2022). The influence of non-carious lesions in the surgical treatment of gingival recession: A systematic review and meta-analysis. Journal of Dentistry, 117, 103922. https://doi.org/10.1016/j.jdent.2021.103922
✔ Kasaj, A., & Willershausen, B. (2021). Treatment of gingival recession: When and how? International Dental Journal, 71(3), 178–187. https://doi.org/10.1111/idj.12617
✔ Rajapakse, P. S., McCracken, G. I., Gwynnett, E., Steen, N. D., Guentsch, A., & Heasman, P. A. (2007). Does tooth brushing influence the development and progression of non-inflammatory gingival recession? A systematic review. Journal of Clinical Periodontology, 34(12), 1046–1061. https://doi.org/10.1111/j.1600-051X.2007.01149.x

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Updated Treatments for Gummy Smile: What Works Today

Excessive gingival display (EGD), commonly referred to as a gummy smile, is a multifactorial esthetic condition in which an excessive amount of maxillary gingiva is visible during smiling.

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Although gingival exposure of approximately 1–2 mm may be considered within an esthetically acceptable range, the clinical significance of EGD depends on facial proportions, lip dynamics, tooth dimensions, gingival architecture, and patient perception.

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Current management emphasizes etiologic diagnosis rather than a single universal treatment. Altered passive eruption, dentoalveolar extrusion, vertical maxillary excess, gingival enlargement, short or hypermobile upper lip, and combinations of these factors may coexist.
Therefore, treatment selection should be based on a comprehensive periodontal, dental, orthodontic, and facial assessment.

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✅ Diagnosis Before Treatment
A predictable treatment plan begins with identifying the principal source of gingival exposure. Clinical evaluation should include:

▪️ Gingival display during posed and maximum smile.
▪️ Upper lip length and mobility.
▪️ Maxillary incisor display at rest and during smiling.
▪️ Clinical crown dimensions and tooth proportions.
▪️ Periodontal probing and assessment of the cementoenamel junction.
▪️ Incisor inclination and vertical position.
▪️ Occlusal relationships and overbite.
▪️ Facial proportions and lower anterior facial height.
▪️ Cephalometric assessment when vertical maxillary excess is suspected.
This diagnostic process is particularly important because treating only one component of a multifactorial gummy smile may produce an incomplete or unstable esthetic result.

✅ Updated Treatment Options for Gummy Smile

Etiologic Factor	Preferred Treatment Approach	Main Clinical Objective
Altered passive eruption	Esthetic crown lengthening ± osseous recontouring	Increase clinical crown exposure
Dentoalveolar extrusion	Orthodontic intrusion, frequently with TAD-supported anchorage	Reposition the incisors apically
Hypermobile upper lip	Lip repositioning or botulinum toxin type A	Reduce excessive upper-lip elevation
Vertical maxillary excess	Orthognathic surgery	Correct the underlying skeletal discrepancy
Gingival enlargement	Periodontal therapy, gingivectomy, or appropriate surgical correction	Reduce excessive gingival tissue
Multifactorial EGD	Multidisciplinary treatment	Address dental, periodontal, skeletal, and muscular components

1. Esthetic Crown Lengthening
Esthetic crown lengthening is particularly appropriate when excessive gingival display results from altered passive eruption or excessive gingival coverage of otherwise adequately proportioned teeth.
The procedure may involve gingivectomy alone or, when necessary, apical repositioning with osseous recontouring to establish an appropriate supracrestal tissue relationship. The American Academy of Periodontology recognizes crown lengthening as an approach for exposing additional tooth structure when excessive gingival tissue makes the teeth appear short.
Importantly, crown lengthening should not be used to compensate for a skeletal or muscular etiology.

2. Orthodontic Intrusion
When EGD is associated with maxillary incisor or anterior dentoalveolar extrusion, orthodontic intrusion can reduce gingival exposure while preserving the periodontal architecture.
Temporary anchorage devices (TADs) have expanded the clinician's ability to achieve controlled anterior intrusion while minimizing unwanted posterior movement. Recent evidence suggests that TAD-supported mechanics can provide favorable intrusion outcomes, although the certainty of evidence remains limited and treatment protocols vary.
This approach is especially relevant when EGD is accompanied by deep overbite, excessive incisor display, or an unfavorable vertical incisor position.

3. Lip Repositioning
Lip repositioning surgery reduces the upward movement of the upper lip by limiting vestibular muscle excursion. It is most appropriate when upper-lip hypermobility is a major contributor and there is no major skeletal discrepancy requiring orthognathic correction.
A systematic review and meta-analysis reported an overall reduction in gingival display of approximately 3 mm at 6 months, with reductions remaining measurable at 12 and 36 months. Some modified techniques, particularly those incorporating periosteal suturing, demonstrated greater reductions.
However, patient selection remains important because recurrence or partial relapse can occur, particularly during the early postoperative period.

4. Botulinum Toxin Type A
Botulinum toxin type A (BTX-A) is a minimally invasive option for patients whose EGD is predominantly associated with hyperactivity of the upper-lip elevator muscles.
Systematic reviews and meta-analyses demonstrate a clinically relevant short-term reduction in gingival exposure. One meta-analysis reported an average reduction of approximately 3.4 mm at two weeks, with the effect progressively diminishing and tending to approach baseline by approximately 24 weeks.
Consequently, BTX-A should be regarded as a temporary treatment, rather than a definitive correction of skeletal or dental abnormalities. It can be particularly useful when the patient prefers a minimally invasive approach or when muscle hyperactivity is the dominant etiologic factor.

5. Orthognathic Surgery
When vertical maxillary excess is the principal cause of excessive gingival display, Le Fort I maxillary impaction or another appropriately planned orthognathic procedure may provide the most comprehensive correction.
Unlike treatments directed primarily at gingival tissue or lip dynamics, orthognathic surgery addresses the underlying skeletal discrepancy. Current evidence supports its role particularly in patients with significant vertical maxillary excess, although treatment involves substantially greater morbidity and requires multidisciplinary planning.

6. Multidisciplinary and Combined Treatment
Many patients do not have a single etiologic factor. For example, altered passive eruption may coexist with incisor extrusion and upper-lip hypermobility.
In such cases, combined treatment may provide a more predictable result than attempting to correct all gingival exposure through one procedure. Periodontal surgery, orthodontic intrusion, lip repositioning, BTX-A, or orthognathic surgery should therefore be considered according to the dominant etiologic components rather than simply the amount of gingiva displayed.

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✅ Clinical Decision-Making
A practical treatment sequence is:
Diagnosis → Etiologic classification → Severity assessment → Identify dominant factor → Select the least invasive effective treatment → Evaluate residual EGD → Consider combined therapy when indicated.
The objective should not simply be to eliminate every millimeter of visible gingiva. Facial harmony, tooth–lip relationships, periodontal health, and patient expectations should determine the final treatment target.

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💬 Discussion
The contemporary management of gummy smile has shifted from procedure-driven correction toward etiology-driven treatment planning. The available evidence supports several effective interventions, but their indications differ substantially.
Crown lengthening is highly appropriate for altered passive eruption, whereas orthodontic intrusion addresses an unfavorable dentoalveolar position. Lip repositioning and BTX-A primarily target excessive lip elevation, while orthognathic surgery is indicated when the underlying problem is skeletal.
The evidence is strongest for the principle that accurate diagnosis is fundamental, while comparative evidence between many treatment modalities remains limited. Recent systematic reviews also emphasize heterogeneity in patient selection, treatment protocols, outcome measurements, and follow-up periods.
Therefore, treatment should be individualized rather than based exclusively on a numerical gingival-display threshold.

🎯 Clinical Recommendations
1. Determine the etiology before selecting the procedure.
2. Use esthetic crown lengthening when altered passive eruption is the primary cause.
3. Consider TAD-assisted orthodontic intrusion when excessive incisor vertical position contributes to EGD.
4. Reserve lip repositioning primarily for patients with clinically significant upper-lip hypermobility.
5. Consider BTX-A when muscle hyperactivity predominates and a temporary, minimally invasive correction is acceptable.
6. Evaluate orthognathic surgery when vertical maxillary excess is clinically significant.
7. In multifactorial cases, consider sequential or combined interdisciplinary treatment rather than overcorrecting a single component.

✍️ Conclusion
Updated gummy smile treatment is increasingly based on individualized etiologic diagnosis rather than a single corrective technique. Crown lengthening, orthodontic intrusion, lip repositioning, botulinum toxin, and orthognathic surgery each have specific indications and limitations.
The most predictable results are achieved when clinicians identify the relative contribution of the periodontal, dental, skeletal, and muscular components before treatment. For complex cases, interdisciplinary planning remains essential to achieve stable and proportionate smile esthetics.

📚 References

✔ Ahmad Amro, L., et al. (2026). Prevalence of different etiologies of excessive gingival display: Identifying diagnostic patterns. The Scientific World Journal.
✔ AlMaghlouth, B., AlMubarak, A., Almaghlouth, I., AlKhalifah, R., Alsadah, A., & Hassan, A. (2021). Orthodontic intrusion using temporary anchorage devices compared to other orthodontic intrusion methods: A systematic review. Clinical, Cosmetic and Investigational Dentistry, 13, 11–19. https://doi.org/10.2147/CCIDE.S283102
✔ Dym, H., & Pierre, R. (2020). Diagnosis and treatment approaches to a “gummy smile.” Dental Clinics of North America, 64(2), 341–349. https://doi.org/10.1016/j.cden.2019.12.003
✔ Mendoza-Geng, A., Gonzales-Medina, K., Meza-Mauricio, J., Muniz, F. W. M. G., & Vergara-Buenaventura, A. (2022). Clinical efficacy of lip repositioning technique and its modifications for the treatment of gummy smile: Systematic review and meta-analysis. Clinical Oral Investigations, 26(6), 4243–4261. https://doi.org/10.1007/s00784-022-04467-0
✔ Pavone, A. F., Ghassemian, M., & Verardi, S. (2016). Gummy smile and short tooth syndrome—Part 1: Etiopathogenesis, classification, and diagnostic guidelines. Compendium of Continuing Education in Dentistry, 37(2), 102–107.
Silberberg, N., Goldstein, M., & Smidt, A. (2009). Excessive gingival display—Etiology, diagnosis, and treatment modalities. Quintessence International, 40(10), 809–818.
✔ Tomaz, A. F. G., et al. (2020). Impact of orthognathic surgery on the treatment of gummy smile: An integrative review. Oral and Maxillofacial Surgery.
✔ Vilarinho, D. F., et al. (2023). Contemporary treatment techniques for excessive gingival display caused by altered passive eruption or lip hypermobility. Journal of Esthetic and Restorative Dentistry.

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Dexamethasone Use in Periodontal Surgery: Pros & Cons

Dexamethasone use in periodontal surgery has been investigated as a perioperative strategy to reduce the inflammatory response associated with surgical manipulation of periodontal tissues.

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Because postoperative pain and edema can affect comfort, mastication, and recovery, corticosteroids may provide an adjunctive benefit when appropriately selected.

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Current evidence suggests that perioperative dexamethasone can reduce postoperative pain and swelling, particularly during the first several days after periodontal flap surgery.
However, its benefits should be balanced against patient-specific contraindications, potential adverse effects, and the limited number of high-quality periodontal studies.

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✅ How Dexamethasone Works in Periodontal Surgery
Dexamethasone is a potent glucocorticoid with anti-inflammatory activity. It suppresses multiple inflammatory pathways, including the production of prostaglandins and other mediators involved in vascular permeability, tissue edema, and postoperative pain.
In periodontal surgery, this mechanism may attenuate the acute inflammatory response produced by flap elevation, tissue manipulation, and surgical trauma.
Importantly, dexamethasone is an adjunct to surgical and analgesic management, not a substitute for atraumatic surgical technique or appropriate postoperative analgesia.

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✅ Benefits of Dexamethasone in Periodontal Surgery

1. Reduction of postoperative pain
Randomized clinical trials have demonstrated a reduction in postoperative pain following periodontal flap surgery when dexamethasone is administered perioperatively.
A randomized trial involving 60 patients undergoing open-flap debridement found that an 8-mg preoperative dose of dexamethasone provided greater pain control and reduced the need for rescue acetaminophen compared with placebo.
More recently, a randomized crossover trial found that 8 mg of intravenous dexamethasone administered before periodontal flap surgery significantly reduced pain during the first 72 hours compared with placebo.

2. Reduction of postoperative swelling
The anti-inflammatory effect of dexamethasone may also reduce postoperative edema.
In the 2022 randomized trial, intravenous dexamethasone was associated with significantly less swelling during several postoperative assessment periods, including the early postoperative phase.
A 2024 randomized clinical study also reported less swelling on the first postoperative day after submucosal administration of 8 mg dexamethasone during periodontal flap surgery.

3. Potential improvement in early postoperative function
Reduction of inflammatory edema may facilitate early oral function. The 2024 submucosal study reported improved chewing efficiency and less reduction in mouth opening during the early postoperative period. However, these findings should be interpreted cautiously because the study included only 25 patients.

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✅ Routes and Timing of Administration
Dexamethasone has been studied through several administration routes, including oral, intravenous, and submucosal administration.

Approach	Evidence in Periodontal Surgery	Main Consideration
Preoperative oral	Evidence of reduced postoperative pain	Convenient; evidence remains limited
Intravenous	Reduced pain and swelling in randomized clinical trials	Useful when IV access is already established
Submucosal	Recent evidence suggests reduced pain and swelling	Avoids the need for IV access
Repeated postoperative dosing	Less consistently studied	Greater exposure is not necessarily associated with greater benefit

Factor	Clinical implication
Timing	Preoperative or perioperative administration is the approach most consistently investigated.
Dose	Studies have commonly evaluated single doses of 4–8 mg, but no universally established periodontal surgery regimen exists.
Route	IV and submucosal administration have demonstrated clinical effects; the optimal route remains uncertain.

The evidence should therefore not be interpreted as establishing 8 mg as a universal standard dose. The 8-mg regimen has been studied in clinical trials, but patient characteristics, surgical extent, route of administration, and local prescribing regulations must be considered.

✅ Limitations and Safety Considerations

1. Evidence remains limited
A 2024 systematic review identified only six randomized clinical trials involving 250 participants evaluating preemptive steroidal and nonsteroidal analgesia in periodontal surgery. The authors noted substantial methodological limitations, including risk of bias and heterogeneity in drugs and doses.
Consequently, dexamethasone should be regarded as a selective adjunct rather than routine therapy for every periodontal surgical procedure.

2. Hyperglycemia
Systemic corticosteroids can transiently increase blood glucose concentrations. This is particularly relevant in patients with diabetes or impaired glucose regulation.
Patient-specific risk assessment is therefore important before administration, especially when systemic corticosteroids are being considered.

3. Infection considerations
Corticosteroids suppress immune responses and can potentially exacerbate or mask infection. Current prescribing information warns that corticosteroids may reduce resistance to infection and obscure clinical signs of infection.
This does not mean that a single perioperative dose inevitably causes infection. Indeed, a large Cochrane review of perioperative dexamethasone in surgical patients found no evidence of increased postoperative wound infection with a single perioperative steroid exposure.
Nevertheless, dexamethasone should not be used to mask an inadequately controlled infection or as a substitute for appropriate antimicrobial or surgical management.

4. Not a replacement for conventional analgesia
Dexamethasone primarily modifies the inflammatory component of postoperative morbidity. It should not automatically replace evidence-based analgesic therapy.
Current dental pain guidelines support NSAIDs, alone or combined with acetaminophen, as first-line pharmacologic therapy for acute dental pain when not contraindicated.

5. Limited evidence regarding long-term periodontal outcomes
Most studies evaluate short-term outcomes such as pain, swelling, trismus, and analgesic consumption. There is insufficient evidence to conclude that perioperative dexamethasone improves long-term periodontal healing, attachment gain, or regenerative outcomes.

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💬 Discussion
The current evidence supports a potential role for perioperative dexamethasone as an adjunct in periodontal surgery, particularly when postoperative inflammation is expected to be clinically significant.
The strongest periodontal evidence concerns reduction of early postoperative pain and swelling. Both intravenous and submucosal administration have demonstrated beneficial effects in randomized trials, while a recent systematic review supports the potential effectiveness of preemptive dexamethasone for postoperative pain.
However, the evidence base remains relatively small and heterogeneous. The 2024 systematic review specifically highlighted methodological limitations and the need for additional well-designed randomized trials.
Therefore, the clinical decision should be individualized rather than protocol-driven. Dexamethasone may be particularly reasonable when substantial postoperative inflammation is anticipated, while routine administration for uncomplicated periodontal procedures offers less clearly established incremental benefit.

✍️ Conclusion
Dexamethasone can reduce postoperative pain and swelling following periodontal surgery, with evidence supporting both systemic and local administration. Its anti-inflammatory effect makes it a potentially useful perioperative adjunct, particularly for procedures associated with greater tissue trauma.
Nevertheless, dexamethasone is not universally indicated. The relatively limited periodontal evidence, potential systemic effects, glucose elevation, infection-related considerations, and absence of demonstrated long-term periodontal benefits support a selective, patient-centered approach.
The most appropriate use is therefore as an adjunct to atraumatic surgical technique and evidence-based analgesia, rather than as routine medication for all periodontal surgical patients.

🎯 Clinical Recommendations
▪️ Consider perioperative dexamethasone selectively when postoperative pain or edema is expected to be clinically significant.
▪️ Do not interpret the commonly studied 8-mg dose as a universal periodontal protocol; dosing should be individualized according to the clinical situation and route of administration.
▪️ Consider submucosal administration when an IV route is unnecessary; current evidence suggests it can provide postoperative benefits without clear superiority of IV administration for pain or analgesic consumption.
▪️ Evaluate diabetes, infection, immunosuppression, corticosteroid exposure, and other relevant medical conditions before prescribing.
▪️ Maintain conventional evidence-based analgesia; dexamethasone should generally be considered an adjunct rather than a replacement for NSAID-based analgesic strategies when these are appropriate.
▪️ Avoid routine corticosteroid use when the expected inflammatory burden is low and the potential benefit is unlikely to justify systemic exposure.
▪️ Explain to patients that the principal expected benefit is short-term reduction of postoperative inflammatory symptoms, not improvement of long-term periodontal healing.

📚 References

✔ Altindal, D., Alsafadi, A., Alshujaa, B., Talmac, A. C., Ege, B., Calisir, M., & Alpaslan, N. Z. (2024). Effect of submucosal dexamethasone on postoperative pain, swelling and trismus after periodontal surgery: A randomized clinical study. Clinical Oral Investigations, 28(12), 681. https://doi.org/10.1007/s00784-024-06076-5
✔ Carrasco-Labra, A., Polk, D. E., Urquhart, O., Aghaloo, T., Claytor, J. W., Jr., Dhar, V., Dionne, R. A., Espinoza, L., Gordon, S. M., Hersh, E. V., Law, A. S., Li, B. S.-K., Schwartz, P. J., Suda, K. J., Turturro, M. A., Wright, M. L., Dawson, T., Miroshnychenko, A., Pahlke, S., Pilcher, L., Shirey, M., Tampi, M., & Moore, P. A. (2024). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. Journal of the American Dental Association, 155(2), 102–117.e9. https://doi.org/10.1016/j.adaj.2023.10.009
✔ Lages, L. P. de D., Bergamaschi, C. de C., Lopes, L. C., da Frota, E. G., Silva, M. T., Monte, T. L., & Motta, R. H. L. (2024). Preemptive oral analgesia with steroidal and nonsteroidal anti-inflammatory drugs in periodontal surgery: A systematic review. Frontiers in Pharmacology, 15, 1385401. https://doi.org/10.3389/fphar.2024.1385401
✔ Vieth, M. P., Deas, D. E., Palaiologou, A. A., Diogenes, A., Mader, M. J., & Mealey, B. L. (2022). Effect of intravenous dexamethasone on postoperative pain and swelling following periodontal flap surgery: A randomized controlled trial of patient-centered outcomes. Journal of Periodontology, 93(2), 237–245. https://doi.org/10.1002/JPER.21-0153
✔ Wagner, J. C., Johnson, T. M., & Gilbert, W. A. (2022). Should periodontists prescribe postoperative oral corticosteroids to control pain and swelling? A systematic review. Clinical Advances in Periodontics, 12(2), 134–142. https://doi.org/10.1002/cap.10169
✔ Sauerland, S., Nagelschmidt, M., Mallmann, P., & Neugebauer, E. A. M. (2019). Adverse side-effects of dexamethasone in surgical patients—An abridged Cochrane systematic review. Anaesthesia, 74(8), 1013–1020. https://doi.org/10.1111/anae.14610
✔ Green, V. G., Polk, D. E., Turturro, M. A., Moore, P. A., & Carrasco-Labra, A. (2025). Evidence-based clinical practice guidelines for the management of acute dental pain. American Journal of Emergency Medicine, 89, 247–253. https://doi.org/10.1016/j.ajem.2024.12.054

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What Is Peri-Implantitis? How Does It Affect Dental Implants?

Peri-implantitis is an inflammatory disease that affects the tissues surrounding a dental implant. Unlike peri-implant mucositis, which is limited to inflammation of the soft tissues, peri-implantitis is associated with progressive loss of the bone supporting the implant.

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The condition is mainly associated with the accumulation of dental plaque and bacterial biofilm, although several patient-, implant-, and prosthesis-related factors can increase the risk. If left untreated, peri-implantitis may progressively compromise implant stability and, in advanced cases, lead to implant failure.

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✅ What Is Peri-Implantitis?
Peri-implantitis is a plaque-associated inflammatory disease characterized by inflammation of the tissues around a dental implant and progressive loss of supporting bone.
It should be distinguished from peri-implant mucositis:

Condition	Main feature	Bone loss
Peri-implant health	No clinical signs of inflammation	No progressive bone loss
Peri-implant mucositis	Inflammation and bleeding around the implant	No progressive bone loss
Peri-implantitis	Inflammation with bleeding and/or suppuration	Progressive supporting bone loss

The distinction is clinically important because peri-implant mucositis can often be controlled before bone destruction occurs, whereas peri-implantitis requires assessment of both the soft tissues and the supporting bone.

✅ How Does Peri-Implantitis Develop?
The process usually begins with the accumulation of bacterial biofilm around the implant. This can trigger inflammation in the surrounding soft tissues.
If the inflammatory process persists, it may extend deeper and contribute to loss of the bone supporting the implant.
However, plaque is not the only consideration. Current evidence indicates that peri-implantitis results from the interaction of biofilm, patient susceptibility, implant characteristics, and local conditions.
Important Risk Factors
Recent AO/AAP evidence identifies several factors that may increase the risk of peri-implant diseases:
▪️ Previous periodontitis
▪️ Smoking
▪️ Poor plaque control
▪️ Uncontrolled diabetes
▪️ Obesity
▪️ Poorly positioned implants
▪️ Prosthetic factors that make cleaning difficult
▪️ Certain unfavorable peri-implant soft-tissue conditions
Among these, a history of periodontitis and cigarette smoking have particularly strong evidence as risk factors for peri-implantitis.

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✅ Signs and Symptoms of Peri-Implantitis
Peri-implantitis may not always cause pain, so patients can have disease progression without obvious symptoms.
Possible warning signs include:
▪️ Bleeding when brushing or during professional probing
▪️ Redness or swelling around the implant
▪️ Suppuration or pus
▪️ Increasing probing depth
▪️ Gum recession around the implant
▪️ Unpleasant taste or odor in some cases
▪️ Progressive radiographic bone loss
▪️ Mobility of the implant in advanced cases
A particularly important point is that implant mobility is generally a late finding. An implant that becomes mobile may already have experienced substantial loss of supporting bone.

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✅ How Is Peri-Implantitis Diagnosed?
Diagnosis requires more than simply observing redness around an implant.
The clinician evaluates the peri-implant tissues through:
1. Clinical examination
2. Gentle periodontal probing
3. Assessment of bleeding and/or suppuration
4. Comparison of probing depths with previous records
5. Radiographic evaluation of bone levels
6. Evaluation of prosthetic and implant-related factors
Whenever possible, baseline probing and radiographic measurements should be recorded after completion of the implant-supported restoration. These measurements make future changes easier to identify.
When previous records are unavailable, the 2017 classification proposed the combination of bleeding and/or suppuration, probing depths of ≥6 mm, and bone levels ≥3 mm apical to the most coronal portion of the intraosseous implant as criteria consistent with peri-implantitis.
These numerical criteria should not, however, replace clinical judgment and comparison with previous examinations.

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✅ How Does Peri-Implantitis Affect a Dental Implant?
The main concern is progressive loss of the bone that supports the implant.
As bone is lost, the implant may become increasingly exposed and its long-term stability can be compromised. Advanced disease may also create deeper areas that are more difficult for the patient to clean, potentially sustaining the inflammatory process.
The clinical consequence can therefore be summarized as:
Biofilm accumulation → inflammation → progressive bone loss → reduced implant support → possible implant failure.
Importantly, peri-implantitis does not automatically mean that an implant must be removed. Treatment depends on disease severity, bone defects, implant position, prosthetic design, patient risk factors, and the response to treatment. Current consensus recommendations emphasize individualized management rather than a single treatment protocol for every case.

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✅ How Is Peri-Implantitis Treated?
Treatment aims to control inflammation, reduce bacterial contamination, manage contributing risk factors, and preserve or restore peri-implant tissues when possible.

1. Non-Surgical Management
Initial treatment may include:
Professional mechanical debridement
Improvement of the patient's oral hygiene
Management of modifiable risk factors
Correction of local factors that interfere with plaque control
A personalized supportive maintenance program
For some patients, nonsurgical therapy can reduce inflammation, but established peri-implantitis may require additional treatment when inflammation and bone loss persist.

2. Surgical Management
More advanced cases may require surgical treatment to obtain access to the affected implant surface and manage the bone defect.
Depending on the defect and clinical situation, treatment may involve:
▪️ Access-flap surgery
▪️ Resective procedures
▪️ Regenerative procedures
▪️ Soft-tissue augmentation when indicated
▪️ Implant removal in selected cases where the implant cannot be predictably maintained
The 2025 AO/AAP consensus emphasizes that treatment should be individualized according to disease severity and patient- and site-specific factors, followed by supportive peri-implant maintenance.

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💬 Discussion
Peri-implantitis is one of the most important biological complications associated with long-term implant therapy. Current evidence supports viewing it as a multifactorial inflammatory disease, rather than simply an infection caused by poor oral hygiene.
Its clinical importance lies in the potential for progressive bone destruction around an otherwise functional implant. Prevention and early detection are therefore essential.
Recent AO/AAP evidence estimated patient-level prevalence of peri-implantitis at approximately 21%, although prevalence varies substantially according to diagnostic criteria, study populations, and follow-up periods.
The most important practical message is that implant therapy does not end when the prosthesis is delivered. Long-term maintenance, plaque control, management of risk factors, and periodic clinical and radiographic monitoring are essential components of implant care.

✍️ Conclusion
Peri-implantitis is a plaque-associated inflammatory disease that causes progressive loss of bone around a dental implant. It differs from peri-implant mucositis because bone destruction is a defining feature.
Although peri-implantitis can threaten the long-term stability of an implant, early diagnosis and appropriate management can help control disease progression. Patients with a history of periodontitis, smokers, and individuals with inadequate plaque control or other risk factors require particular attention.
Successful implant therapy therefore depends not only on implant placement and restoration, but also on lifelong peri-implant maintenance and risk-factor management.

🎯 Clinical Recommendations
▪️ Establish baseline probing and radiographic records after implant restoration whenever possible.
▪️ Do not wait for pain or implant mobility before investigating suspicious peri-implant changes.
▪️ Bleeding on probing should be taken seriously, particularly when it is persistent or accompanied by increasing probing depths.
▪️ Identify and manage modifiable risk factors, especially smoking, poor plaque control, and uncontrolled diabetes.
▪️ Assess whether the prosthesis or implant position makes effective plaque removal difficult.
▪️ Treat peri-implant mucositis early to reduce the risk of progression.
▪️ For established peri-implantitis, use a severity- and defect-specific treatment plan and maintain the patient in supportive peri-implant care.

📚 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 Periodontology, 89(Suppl. 1), S313–S318. https://doi.org/10.1002/JPER.17-0739
✔ Fiorellini, J. P., Mojaver, S., Sarmiento, H., & Aghaloo, T. (2025). Clinical translation of the 2024 AO/AAP consensus on prevention and management of peri-implant diseases and conditions. The International Journal of Periodontics & Restorative Dentistry, 45(4), 1–30. https://doi.org/10.11607/prd.7658
✔ Galarraga-Vinueza, M. E., Pagni, S., Finkelman, M., Schoenbaum, T., & Chambrone, L. (2025). Prevalence, incidence, systemic, behavioral, and patient-related risk factors and indicators for peri-implant diseases: An AO/AAP systematic review and meta-analysis. Journal of Periodontology, 96(6), 587–633. https://doi.org/10.1002/JPER.24-0154
✔ Renvert, S., Persson, G. R., Pirih, F. Q., & Camargo, P. M. (2018). Peri-implant health, peri-implant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. Journal of Periodontology, 89(Suppl. 1), S304–S312. https://doi.org/10.1002/JPER.17-0588
✔ Wang, H.-L., Avila-Ortiz, G., Monje, A., Kumar, P., Calatrava, J., Aghaloo, T., Barootchi, S., Fiorellini, J. P., Galarraga-Vinueza, M. E., Kan, J., Lin, G.-H., Ravida, A., Saleh, M. H. A., Tavelli, L., & Rosen, P. S. (2025). AO/AAP consensus on prevention and management of peri-implant diseases and conditions: Summary report. Journal of Periodontology, 96(6), 519–541. https://doi.org/10.1002/JPER.25-0270

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