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

Two diseases, one origin

Around an implant, the gum (the peri-implant mucosa) does not attach to the surface as it does to a tooth: it sits against it as a cuff of tissue, without a ligament. This difference leaves it less well armed against bacterial plaque.

Peri-implant mucositis is inflammation of this mucosa, without bone loss. Its cardinal sign is bleeding of the mucosa around the implant. It is reversible: signs of inflammation may nonetheless take more than three weeks to fade once plaque control is restored ^[1].

Peri-implantitis adds to this inflammation a 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]. Without a baseline examination, diagnosis rests on bleeding or pus around the implant and on 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), taken up in the 2023 European guideline, put prevalence at about 43% of patients for mucositis and 22% for peri-implantitis ^[2][3]. These figures call for caution: definitions varied from study to study, and the confidence interval was wide (14 to 30% for peri-implantitis). They nonetheless establish that this is a common problem, not a rarity.

Who is most at risk?

The 2018 consensus separates factors whose role is well established from those 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 names 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 common-sense measures. Other elements count 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 pride of place ^[3]. Among its strongest recommendations:

• Before the implant: treat gingivitis or periodontitis to stability (gums that no longer bleed) and follow a maintenance programme before placement.
• At the planning stage: leave enough space between the implant and neighbouring teeth, choose a suitable placement depth and a prosthesis that lets oral hygiene aids through.
• After placement: take a baseline X-ray once bone remodelling is complete, then check the mucosa around the implant at every visit.
• Day to day: receive individually tailored oral hygiene instructions.
• Long term: attend regular supportive peri-implant care, even when all is well.

The guideline sets no interval valid for every healthy patient: it is tailored to risk. A 2016 meta-analysis, based on observational studies, likewise urged caution in reading its results and personalising the schedule ^[4]. After treatment of peri-implantitis, the 2023 guideline suggests closer follow-up, then individually adjusted ^[3]. The frequency is therefore set at the practice according to your risk, and this follow-up forms 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 settles on implants just as it does on teeth, and the most exposed area is the junction between crown and 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, bristles angled 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; too thin, it does not clean, too thick, it 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 slipped under the pontic, or an angled brush.
• Water flosser: the jet dislodges debris and rounds off the 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, say so: thickening the mucosa can sometimes be considered ^[3].

No brand stands out: what matters is the size of the brush, the regularity of the routine and, at follow-up visits, checking the areas where plaque lingers. The sizes suited to each space are indicated at the practice and reviewed as the gum changes.

Warning signs

Peri-implantitis is usually painless at first, like periodontitis. All the more reason to know its early, discreet signs:

• red, swollen gum, or gum that bleeds when brushing or when the interdental brush passes 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 told apart from mobility of the implant itself, which indicates advanced loss of anchorage.

If one of these signs appears, do not wait for your next appointment. Mucositis caught at this stage is treated simply; peri-implantitis detected early, through examination of the mucosa 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 pairs professional cleaning of the implant and prosthesis with effective plaque control at home ^[3]. A short course of antiseptic mouthwash may be considered. The guideline, however, suggests neither adding air-polishing to professional cleaning nor photodynamic therapy, and does not recommend local or systemic antibiotics.

Peri-implantitis. Treatment begins 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]. Routine systemic antibiotics are not recommended.

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 examined, cleaned with instruments that respect 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 identical for implants placed there and for those placed elsewhere; bringing the baseline X-ray, when you have it, makes it possible to judge the progression from the very first visit.

Frequently asked questions

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