Peri-implantitis pathogenesis: Novel insights may guide therapeutic interventions

This narrative review expands on the concept of inflammation created by metal particles and ions that originate from dental implants and suggests preventative and therapeutic approaches to reduce the problem.

A review and discussion of various etiologic factors for peri-implant mucositis and peri-implantitis are presented, including: foreign body response to embedded residual cement or metal particles or ions, corrosion of the titanium oxide (TiO) layer, tribocorrosion, human and animal histology and studies, treatments, prevention, and maintenance.

The understanding of etiologic factors for peri-implant mucositis and peri-implantitis and their effect on treatment is an evolving science. Biofilm remains a primary etiologic factor. However, a foreign body response from residual cement or metal particles or ions (i.e., metallosis) has been implicated in the onset and progression of peri-implantitis. While further elucidation of risk factors is appropriate, the treatment adaptations needed to reduce metallosis are simple and easy to apply and should be considered for inclusion in routine diagnosis, therapy, and maintenance.

Concepts regarding the etiology and management of inflammatory lesions around dental implants continue to evolve. While bacterial biofilm is widely recognized as the primary etiologic factor, additional contributors such as excess cement and metallic particles acting as foreign bodies have been increasingly emphasized in the literature. These foreign materials act synergistically with biofilm to amplify the inflammatory response. Ions and particles released from implant surfaces can initiate an immunoinflammatory cascade, ultimately resulting in peri-implant bone loss, a process referred to as metallosis. Unlike the removal of excess cement, which can often be mitigated through judicious cementation techniques or, preferably, the use of screw-retained restorations, the reduction of metallic particles presents greater clinical challenges. Such particles may originate from biofilm-induced corrosion, occlusal overload, or even therapeutic interventions aimed at treating peri-implant inflammation. Minimally invasive strategies have been proposed to address these challenges. Approaches such as the careful use of cotton pellets with sterile saline, and when indicated, the application of minimally invasive flaps under enhanced visualization, have shown promise in reducing the burden of foreign particles. Importantly, stringent oral hygiene measures and consistent maintenance therapy remain indispensable in mitigating these risks and maintaining peri-implant health.