The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 13, 2019

A Classification Proposal for Peri-Implant Mucositis and Peri-Implantitis: A Critical Update



Javier Ata-Ali1, *, Fadi Ata-Ali2, Leticia Bagan3
1 Public Dental Health Service, Arnau de Vilanova Hospital, European University of Valencia, Spain
2 Valencia University Medical and Dental School, Spain
3 Department of Oral Medicine, Valencia University Medical and Dental School, Spain

Abstract

Definitions of peri-implant mucositis and peri-implantitis vary in the literature, and no clear criteria have been established for the diagnosis and treatment of such disorders. This study proposes a classification for peri-implant mucositis and peri-implantitis based on the severity of the disease, using a combination of peri-implant clinical and radiological parameters to classify severity into several stages (Stage 0A and 0B = peri-implant mucositis, and Stage I to IV = periimplantitis). Following a review of the literature on the subject and justification of the proposed peri-implant disease classification, the latter aims to facilitate professional communication and data collection for research and community health studies.

Keywords:: Classification, dental implant, disease, peri-implant mucositis, peri-implantitis, peri-implant.


Article Information


Identifiers and Pagination:

Year: 2015
Volume: 9
First Page: 393
Last Page: 395
Publisher Id: TODENTJ-9-393
DOI: 10.2174/1874210601509010393

Article History:

Received Date: 30/7/2015
Revision Received Date: 31/8/2015
Acceptance Date: 8/10/2015
Electronic publication date: 11/12/2015
Collection year: 2015

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© Ata-Ali et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the (https://creativecommons.org/licenses/by/4.0/legalcode), which permits unrestricted, noncommercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Public Dental Health Service. Arnau de Vilanova Hospital, c/ San Clemente 12, 46015-Valencia (Spain); Tel: +0034963868501; E-mail: javiataali@hotmail.com





INTRODUCTION

In 1986, Albrektson et al. [1Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success Int J Oral Maxillofac Implants 1986; 1(1): 11-25.
[PMID: 3527955]
] introduced the widely accepted criteria for implant success, accepting 0.2 mm of bone loss annually after the first year and 85% and 80% success rates after 5 and 10 years, respectively. Various degrees of marginal bone loss are normally seen around dental implants, probably reflecting remodeling / adaptation following surgery and during loading. In general, up to 1.5 mm of bone is lost during the first year of function, followed by a period of minimal annual bone loss [2Oh TJ, Yoon J, Misch CE, Wang HL. The causes of early implant bone loss: myth or science? J Periodontol 2002; 73(3): 322-33.
[http://dx.doi.org/10.1902/jop.2002.73.3.322] [PMID: 11922263]
].A number of authors [3Jemt T, Chai J, Harnett J, et al. A 5-year prospective multicenter follow-up report on overdentures supported by osseointegrated implants Int J Oral Maxillofac Implants 1996; 11(3): 291-8.
[PMID: 8752550]
-5Adell R, Eriksson B, Lekholm U, Brånemark PI, Jemt T. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws Int J Oral Maxillofac Implants 1990; 5(4): 347-59.
[PMID: 2094653]
] have estimated that peri-implant bone loss occurs progressively over the first three years. Vandeweghe et al. [6Vandeweghe S, Cosyn J, Thevissen E, Van den Berghe L, De Bruyn H. A 1-year prospective study on Co-Axis implants immediately loaded with a full ceramic crown Clin Implant Dent Relat Res 2012; 14(Suppl. 1): e126-38.
[http://dx.doi.org/10.1111/j.1708-8208.2011.00391.x] [PMID: 22008836]
], in a prospective study of bone loss in 15 implants, showed bone remodeling to continue for 6 months, after which no further changes were observed, with stabilization of bone loss at 1 mm.

The Sixth European Workshop on Periodontics 2008 [7Lindhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology J Clin Periodontol 2008; 35(8)(Suppl.): 282-5.
[http://dx.doi.org/10.1111/j.1600-051X.2008.01283.x] [PMID: 18724855]
], held in Göteborg (Sweden), defined peri-implant mucositis as the presence of inflammation of the peri-implant mucosa without signs of supporting bone loss, while peri-implantitis was defined as the presence of supporting bone loss in addition to inflammation of the mucosa [7Lindhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology J Clin Periodontol 2008; 35(8)(Suppl.): 282-5.
[http://dx.doi.org/10.1111/j.1600-051X.2008.01283.x] [PMID: 18724855]
].In turn, the Seventh European Workshop on Periodontics 2011, held in Segovia (Spain), specified that the key feature of peri-implant mucositis is the presence of bleeding upon probing, while the key feature of peri-implantitis comprises changes in bone crest level associated to bleeding upon probing [8Lang NP, Berglundh T. Periimplant diseases: where are we now?--Consensus of the Seventh European Workshop on Periodontology J Clin Periodontol 2011; 38(Suppl. 11): 178-81.
[http://dx.doi.org/10.1111/j.1600-051X.2010.01674.x] [PMID: 21323713]
].According to the latest definition of the American Academy of Periodontology [9Peri-implant mucositis and peri-implantitis: a current understanding of their diagnoses and clinical implications J Periodontol 2013; 84(4): 436-43. No authors listed
[http://dx.doi.org/10.1902/jop.2013.134001] [PMID: 23537178]
], peri-implant mucositis is a disease in which the presence of inflammation is confined to the softtissues surrounding a dental implant, with no signs of loss of supporting bone following initial bone remodeling during healing, while peri-implantitis is characterized as an inflammatory process around an implant, including both soft tissue inflammation and progressive loss of supporting bone beyond biological bone remodeling [10Sanz M, Chapple IL. Clinical research on peri-implant diseases: consensus report of Working Group 4 J Clin Periodontol 2012; 39(Suppl. 12): 202-6.
[http://dx.doi.org/10.1111/j.1600-051X.2011.01837.x] [PMID: 22533957]
].

Peri-implant probing is essential for establishing a diagnosis of peri-implant disease. Conventional peri-implant probing under appropriate conditions of pressure, such as 0.25 N, does not cause tissue damage [11Heitz-Mayfield LJ. Peri-implant diseases: diagnosis and risk indicators J Clin Periodontol 2008; 35(8)(Suppl.): 292-304.
[http://dx.doi.org/10.1111/j.1600-051X.2008.01275.x] [PMID: 18724857]
]. In addition, parallelized intraoral X-rays should be used in all dental implants to determine possible marginal bone loss, and confirmed bone loss moreover should be quantified. These periapical X-rays must be obtained at implant placement and prosthesis installation in order to allow comparisons with the periapical X-rays obtained on occasion of the periodic patient controls.

Definitions of peri-implantitis and peri-implant mucositis vary in the literature, and no clear criteria have been established for the diagnosis and treatment of these disorders [12Ata-Ali J, Candel-Marti ME, Flichy-Fernández AJ, Peñarrocha-Oltra D, Balaguer-Martinez JF, Diago PM. Peri-implantitis: associated microbiota and treatment 2011.
[http://dx.doi.org/10.4317/medoral.17227]
]. The use of different thresholds referred to probing depth and radiographic bone loss for defining peri-implant diseases gives rise to considerable variability in the reported prevalence of peri-implant diseases. The reported prevalence of peri-implant mucositis varies between 36.3% [13Máximo MB, de Mendonça AC, Alves JF, Cortelli SC, Peruzzo DC, Duarte PM. Peri-implant diseases may be associated with increased time loading and generalized periodontal bone loss: preliminary results J Oral Implantol 2008; 34(5): 268-73.
[http://dx.doi.org/10.1563/1548-1336(2008)34[269:PDMBAW]2.0.CO;2] [PMID: 19170293]
] and 64.6% [14Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects J Clin Periodontol 2006; 33(12): 929-35.
[http://dx.doi.org/10.1111/j.1600-051X.2006.01001.x] [PMID: 17092244]
], while the prevalence of peri-implantitis ranges from 8.9% [14Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects J Clin Periodontol 2006; 33(12): 929-35.
[http://dx.doi.org/10.1111/j.1600-051X.2006.01001.x] [PMID: 17092244]
] to 47.1% [15Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-implantitis related to severity of the disease with different degrees of bone loss J Periodontol 2010; 81(2): 231-8.
[http://dx.doi.org/10.1902/jop.2009.090269] [PMID: 20151801]
]. According to Hallström et al. [16Hallström H, Persson GR, Lindgren S, Olofsson M, Renvert S. Systemic antibiotics and debridement of peri-implant mucositis. A randomized clinical trial J Clin Periodontol 2012; 39(6): 574-81.
[http://dx.doi.org/10.1111/j.1600-051X.2012.01884.x] [PMID: 22571225]
], the infectious etiology of peri-implant mucositis is well documented [17Renvert S, Roos-Jansåker AM, Lindahl C, Renvert H, Rutger Persson G. Infection at titanium implants with or without a clinical diagnosis of inflammation Clin Oral Implants Res 2007; 18(4): 509-16.
[http://dx.doi.org/10.1111/j.1600-0501.2007.01378.x] [PMID: 17517058]
-19Ata-Ali J, Ata-Ali F, Galindo-Moreno P. Treatment of periimplant mucositis: a systematic review of randomized controlled trials Implant Dent 2015; 24(1): 13-8.
[http://dx.doi.org/10.1097/ID.0000000000000190] [PMID: 25621546]
]. Peri-implant mucositis has been defined as the presence of bleeding in response to probing [13Máximo MB, de Mendonça AC, Alves JF, Cortelli SC, Peruzzo DC, Duarte PM. Peri-implant diseases may be associated with increased time loading and generalized periodontal bone loss: preliminary results J Oral Implantol 2008; 34(5): 268-73.
[http://dx.doi.org/10.1563/1548-1336(2008)34[269:PDMBAW]2.0.CO;2] [PMID: 19170293]
-15Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-implantitis related to severity of the disease with different degrees of bone loss J Periodontol 2010; 81(2): 231-8.
[http://dx.doi.org/10.1902/jop.2009.090269] [PMID: 20151801]
, 20Roos-Jansåker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions J Clin Periodontol 2006; 33(4): 290-5.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00906.x] [PMID: 16553638]
-23Koldsland OC, Scheie AA, Aass AM. The association between selected risk indicators and severity of peri-implantitis using mixed model analyses J Clin Periodontol 2011; 38(3): 285-92.
[http://dx.doi.org/10.1111/j.1600-051X.2010.01659.x] [PMID: 21158898]
], while other authors [14Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects J Clin Periodontol 2006; 33(12): 929-35.
[http://dx.doi.org/10.1111/j.1600-051X.2006.01001.x] [PMID: 17092244]
, 20Roos-Jansåker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions J Clin Periodontol 2006; 33(4): 290-5.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00906.x] [PMID: 16553638]
, 21Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions J Clin Periodontol 2006; 33(4): 296-301.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00908.x] [PMID: 16553639]
, 24Zetterqvist L, Feldman S, Rotter B, et al. A prospective, multicenter, randomized-controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis J Periodontol 2010; 81(4): 493-501.
[http://dx.doi.org/10.1902/jop.2009.090492] [PMID: 20367092]
] add the presence of purulent secretion to the definition. The specified probe depth varies between ≥ 4 mm and ≥ 5 mm [14Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects J Clin Periodontol 2006; 33(12): 929-35.
[http://dx.doi.org/10.1111/j.1600-051X.2006.01001.x] [PMID: 17092244]
, 20Roos-Jansåker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions J Clin Periodontol 2006; 33(4): 290-5.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00906.x] [PMID: 16553638]
-22Karbach J, Callaway A, Kwon YD, d’Hoedt B, Al-Nawas B. Comparison of five parameters as risk factors for peri-mucositis Int J Oral Maxillofac Implants 2009; 24(3): 491-6.
[PMID: 19587872]
]. Other studies [15Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-implantitis related to severity of the disease with different degrees of bone loss J Periodontol 2010; 81(2): 231-8.
[http://dx.doi.org/10.1902/jop.2009.090269] [PMID: 20151801]
, 23Koldsland OC, Scheie AA, Aass AM. The association between selected risk indicators and severity of peri-implantitis using mixed model analyses J Clin Periodontol 2011; 38(3): 285-92.
[http://dx.doi.org/10.1111/j.1600-051X.2010.01659.x] [PMID: 21158898]
, 25Ata-Ali J, Flichy-Fernandez AJ, Ata-Ali F, Penarrocha-Diago M, Penarrocha-Diago M. Clinical, microbiologic, and host response characteristics in patients with peri-implant mucositis Int J Oral Maxillofac Implants 2013; 28(3): 883-90.
[http://dx.doi.org/10.11607/jomi.2654] [PMID: 23748323]
] have added the condition of no bone loss to the definition of mucositis, while other investigators propose higher defining thresholds such as radiographic bone loss of up to three threads after the first year of loading [13Máximo MB, de Mendonça AC, Alves JF, Cortelli SC, Peruzzo DC, Duarte PM. Peri-implant diseases may be associated with increased time loading and generalized periodontal bone loss: preliminary results J Oral Implantol 2008; 34(5): 268-73.
[http://dx.doi.org/10.1563/1548-1336(2008)34[269:PDMBAW]2.0.CO;2] [PMID: 19170293]
, 20Roos-Jansåker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions J Clin Periodontol 2006; 33(4): 290-5.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00906.x] [PMID: 16553638]
, 21Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions J Clin Periodontol 2006; 33(4): 296-301.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00908.x] [PMID: 16553639]
].

Different probing depths have been described in the diagnosis of peri-implant tissues with peri-implant mucositis: 2.07 (range 1-3.16 mm) [26Yamalik N, Günday S, Kilinc K, Karabulut E, Berker E, Tözüm TF. Analysis of cathepsin-K levels in biologic fluids from healthy or diseased natural teeth and dental implants Int J Oral Maxillofac Implants 2011; 26(5): 991-7.
[PMID: 22010081]
]; 2.67±0.76 mm [27Jankovic S, Aleksic Z, Dimitrijevic B, Lekovic V, Camargo P, Kenney B. Prevalence of human cytomegalovirus and Epstein-Barr virus in subgingival plaque at peri-implantitis, mucositis and healthy sites. A pilot study Int J Oral Maxillofac Surg 2011; 40(3): 271-6.
[http://dx.doi.org/10.1016/j.ijom.2010.11.004] [PMID: 21145210]
]; 2.9±0.7 mm [28Casado PL, Otazu IB, Balduino A, de Mello W, Barboza EP, Duarte ME. Identification of periodontal pathogens in healthy periimplant sites Implant Dent 2011; 20(3): 226-35.
[http://dx.doi.org/10.1097/ID.0b013e3182199348] [PMID: 21613949]
]; 3.42±1.18 mm [29Cortelli SC, Cortelli JR, Romeiro RL, et al. Frequency of periodontal pathogens in equivalent peri-implant and periodontal clinical statuses Arch Oral Biol 2013; 58(1): 67-74.
[http://dx.doi.org/10.1016/j.archoralbio.2012.09.004] [PMID: 23127822]
]; 3.55±0.40 mm [25Ata-Ali J, Flichy-Fernandez AJ, Ata-Ali F, Penarrocha-Diago M, Penarrocha-Diago M. Clinical, microbiologic, and host response characteristics in patients with peri-implant mucositis Int J Oral Maxillofac Implants 2013; 28(3): 883-90.
[http://dx.doi.org/10.11607/jomi.2654] [PMID: 23748323]
]; 5.2±1.3 mm [30Máximo MB, de Mendonça AC, Renata Santos V, Figueiredo LC, Feres M, Duarte PM. Short-term clinical and microbiological evaluations of peri-implant diseases before and after mechanical anti-infective therapies Clin Oral Implants Res 2009; 20(1): 99-108.
[http://dx.doi.org/10.1111/j.1600-0501.2008.01618.x] [PMID: 19126114]
]; and 5.4±1.4 mm [31Duarte PM, de Mendonça AC, Máximo MB, Santos VR, Bastos MF, Nociti FH. Effect of anti-infective mechanical therapy on clinical parameters and cytokine levels in human peri-implant diseases J Periodontol 2009; 80(2): 234-43.
[http://dx.doi.org/10.1902/jop.2009.070672] [PMID: 19186963]
]. For this reason, our classification distinguishes between peri-implant mucositis with a probing depth of less than 4 mm and peri-implant mucositis with a greater probing depth.

Peri-implantitis is defined as the presence of bleeding upon probing and / or pus with concomitant radiographic bone loss [13Máximo MB, de Mendonça AC, Alves JF, Cortelli SC, Peruzzo DC, Duarte PM. Peri-implant diseases may be associated with increased time loading and generalized periodontal bone loss: preliminary results J Oral Implantol 2008; 34(5): 268-73.
[http://dx.doi.org/10.1563/1548-1336(2008)34[269:PDMBAW]2.0.CO;2] [PMID: 19170293]
-15Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-implantitis related to severity of the disease with different degrees of bone loss J Periodontol 2010; 81(2): 231-8.
[http://dx.doi.org/10.1902/jop.2009.090269] [PMID: 20151801]
, 20Roos-Jansåker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions J Clin Periodontol 2006; 33(4): 290-5.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00906.x] [PMID: 16553638]
, 21Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions J Clin Periodontol 2006; 33(4): 296-301.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00908.x] [PMID: 16553639]
, 23Koldsland OC, Scheie AA, Aass AM. The association between selected risk indicators and severity of peri-implantitis using mixed model analyses J Clin Periodontol 2011; 38(3): 285-92.
[http://dx.doi.org/10.1111/j.1600-051X.2010.01659.x] [PMID: 21158898]
, 24Zetterqvist L, Feldman S, Rotter B, et al. A prospective, multicenter, randomized-controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis J Periodontol 2010; 81(4): 493-501.
[http://dx.doi.org/10.1902/jop.2009.090492] [PMID: 20367092]
, 32Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects with progressive bone loss at implants Clin Oral Implants Res 2005; 16(4): 440-6.
[http://dx.doi.org/10.1111/j.1600-0501.2005.01137.x] [PMID: 16117768]
-36Cury PR, Horewicz VV, Ferrari DS, et al. Evaluation of the effect of tumor necrosis factor-alpha gene polymorphism on the risk of peri-implantitis: a case-control study Int J Oral Maxillofac Implants 2009; 24(6): 1101-5.
[PMID: 20162115]
]. The bone loss criteria differ, however: > 0.4 mm after implant loading [15Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-implantitis related to severity of the disease with different degrees of bone loss J Periodontol 2010; 81(2): 231-8.
[http://dx.doi.org/10.1902/jop.2009.090269] [PMID: 20151801]
, 23Koldsland OC, Scheie AA, Aass AM. The association between selected risk indicators and severity of peri-implantitis using mixed model analyses J Clin Periodontol 2011; 38(3): 285-92.
[http://dx.doi.org/10.1111/j.1600-051X.2010.01659.x] [PMID: 21158898]
]; detectable bone loss from the one-year examination and bone level ≥ 1.8 mm [32Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects with progressive bone loss at implants Clin Oral Implants Res 2005; 16(4): 440-6.
[http://dx.doi.org/10.1111/j.1600-0501.2005.01137.x] [PMID: 16117768]
, 33Fransson C, Wennström J, Berglundh T. Clinical characteristics at implants with a history of progressive bone loss Clin Oral Implants Res 2008; 19(2): 142-7.
[http://dx.doi.org/10.1111/j.1600-0501.2007.01448.x] [PMID: 18184340]
]; ≥ 2 mm after implant loading [23Koldsland OC, Scheie AA, Aass AM. The association between selected risk indicators and severity of peri-implantitis using mixed model analyses J Clin Periodontol 2011; 38(3): 285-92.
[http://dx.doi.org/10.1111/j.1600-051X.2010.01659.x] [PMID: 21158898]
]; ≥ 1.8 mm from the one-year examination [13Máximo MB, de Mendonça AC, Alves JF, Cortelli SC, Peruzzo DC, Duarte PM. Peri-implant diseases may be associated with increased time loading and generalized periodontal bone loss: preliminary results J Oral Implantol 2008; 34(5): 268-73.
[http://dx.doi.org/10.1563/1548-1336(2008)34[269:PDMBAW]2.0.CO;2] [PMID: 19170293]
, 20Roos-Jansåker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions J Clin Periodontol 2006; 33(4): 290-5.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00906.x] [PMID: 16553638]
, 21Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions J Clin Periodontol 2006; 33(4): 296-301.
[http://dx.doi.org/10.1111/j.1600-051X.2006.00908.x] [PMID: 16553639]
, 34Laine ML, Leonhardt A, Roos-Jansåker AM, et al. IL-1RN gene polymorphism is associated with peri-implantitis Clin Oral Implants Res 2006; 17(4): 380-5.
[http://dx.doi.org/10.1111/j.1600-0501.2006.01249.x] [PMID: 16907768]
]; > 2 mm after the last radiological control [35Gatti C, Gatti F, Chiapasco M, Esposito M. Outcome of dental implants in partially edentulous patients with and without a history of periodontitis: a 5-year interim analysis of a cohort study Eur J Oral Implantology 2008; 1(1): 45-51.
[PMID: 20467643]
]; ≥ 3 mm of radiological bone loss after abutment placement [37Roccuzzo M, De Angelis N, Bonino L, Aglietta M. Ten-year results of a three-arm prospective cohort study on implants in periodontally compromised patients. Part 1: implant loss and radiographic bone loss Clin Oral Implants Res 2010; 21(5): 490-6.
[http://dx.doi.org/10.1111/j.1600-0501.2009.01886.x] [PMID: 20337668]
]; ≥ 3 mm after implant loading [36Cury PR, Horewicz VV, Ferrari DS, et al. Evaluation of the effect of tumor necrosis factor-alpha gene polymorphism on the risk of peri-implantitis: a case-control study Int J Oral Maxillofac Implants 2009; 24(6): 1101-5.
[PMID: 20162115]
]; or > 5 mm of bone loss [24Zetterqvist L, Feldman S, Rotter B, et al. A prospective, multicenter, randomized-controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis J Periodontol 2010; 81(4): 493-501.
[http://dx.doi.org/10.1902/jop.2009.090492] [PMID: 20367092]
]. Ferreira et al. [14Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects J Clin Periodontol 2006; 33(12): 929-35.
[http://dx.doi.org/10.1111/j.1600-051X.2006.01001.x] [PMID: 17092244]
] in turn define peri-implantitis as the presence of a probing pocket depth of ≥ 5 mm, without mentioning bone loss. A number of studies [38Gruica B, Wang HY, Lang NP, Buser D. Impact of IL-1 genotype and smoking status on the prognosis of osseointegrated implants Clin Oral Implants Res 2004; 15(4): 393-400.
[http://dx.doi.org/10.1111/j.1600-0501.2004.01026.x] [PMID: 15248873]
, 39De Boever AL, Quirynen M, Coucke W, Theuniers G, De Boever JA. Clinical and radiographic study of implant treatment outcome in periodontally susceptible and non-susceptible patients: a prospective long-term study Clin Oral Implants Res 2009; 20(12): 1341-50.
[http://dx.doi.org/10.1111/j.1600-0501.2009.01750.x] [PMID: 19793321]
] have offered no clear definition of peri-implantitis, while another publication [37Roccuzzo M, De Angelis N, Bonino L, Aglietta M. Ten-year results of a three-arm prospective cohort study on implants in periodontally compromised patients. Part 1: implant loss and radiographic bone loss Clin Oral Implants Res 2010; 21(5): 490-6.
[http://dx.doi.org/10.1111/j.1600-0501.2009.01886.x] [PMID: 20337668]
] defined it as radiological bone loss > 3 mm, without taking the clinical parameters into account. As commented by Tomasi et al. [40Tomasi C, Derks J. Clinical research of peri-implant diseases--quality of reporting, case definitions and methods to study incidence, prevalence and risk factors of peri-implant diseases J Clin Periodontol 2012; 39(Suppl. 12): 207-23.
[http://dx.doi.org/10.1111/j.1600-051X.2011.01831.x] [PMID: 22533958]
], the multitude of different disease criteria, the diagnostic and methodological inconsistencies, as well as the variable quality of the reports have so far hampered attempts to draw firm conclusions in the field of peri-implant diseases.

Although there is a classification contemplating three peri-implantitis stages [41Froum SJ, Rosen PS. A proposed classification for peri-implantitis Int J Periodontics Restorative Dent 2012; 32(5): 533-40.
[PMID: 22754901]
] based on the Seventh European Workshop on Periodontics 2011 [8Lang NP, Berglundh T. Periimplant diseases: where are we now?--Consensus of the Seventh European Workshop on Periodontology J Clin Periodontol 2011; 38(Suppl. 11): 178-81.
[http://dx.doi.org/10.1111/j.1600-051X.2010.01674.x] [PMID: 21323713]
], we consider it necessary to unify the concepts of peri-implant mucositis and peri-implantitis within one same classification, since both form part of what we know as peri-implant diseases. A more exhaustive and precise classification of peri-implant diseases is needed with the aim of facilitating communication among investigators and comparison of the different clinical studies.

A recent consensus conference defined peri-implantitis as “infection with suppuration associated to clinically significant progressing crestal bone loss” [42Albrektsson T, Buser D, Sennerby L. On crestal/marginal bone loss around dental implants Int J Prosthodont 2012; 25(4): 320-2.
[PMID: 22720281]
]. Based on this definition, recent 10-year clinical reports on modern implant surfaces have shown low incidences of peri-implantitis. With this definition, the disease incidence according to recent longitudinal studies on modern implant surfaces is < 5% after 10 years of function [43De Bruyn H, Vandeweghe S, Ruyffelaert C, Cosyn J, Sennerby L. Radiographic evaluation of modern oral implants with emphasis on crestal bone level and relevance to peri-implant health Periodontol 2000 2013; 62(1): 256-70.
[http://dx.doi.org/10.1111/prd.12004] [PMID: 23574471]
]. We do not consider suppuration to be a necessary condition for diagnosing peri-implantitis, since in the same way that some cases of moderate and advanced periodontitis can develop without suppuration, certain cases of peri-implantitis may also show no suppuration.

Since there is no clear consensus on peri-implant diseases, we offer the following unified approach to the classification of peri-implant mucositis (Table 1) and peri-implantitis (Table 2).

Table 1

Proposed classification of peri-implant mucositis.




Table 2

Proposed classification of peri-implantitis.




CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

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