Peri-Implantitis: The 60% Problem

The mean long-term disease resolution rate after surgical treatment of peri-implantitis is only 58.6%. This expert review analyzes why surgical treatment fails and what predicts success.

Clinical Tips

By Dr. Mahmoud H. Al-Johani

Why Surgical Treatment Fails and What Predicts Success

By Dr. Mahmoud H. Al-Johani

If you treat dental implants, you will face peri-implantitis. That is not a pessimistic statement. It is epidemiological reality. By the latest consensus estimates, roughly one in five implants develops peri-implantitis within five to ten years of function. And when it arrives, the evidence behind what can be done about it is more sobering than most clinicians realize.

Consider this figure: 58.6%. That is the mean long-term disease resolution rate after surgical treatment of peri-implantitis, according to the most comprehensive systematic review of long-term studies published to date (Monje et al., 2025). Not 90%. Not 80%. Roughly six in ten. And that is under optimal conditions, with patients enrolled in supportive peri-implant care. Without that follow-up, the number drops further.

This article is not about discouragement. It is about honesty. To counsel patients effectively, set expectations, and make evidence-based treatment decisions, the data must be confronted directly. And what the data says is that surgical treatment of peri-implantitis works, but its predictability is fragile, dependent on factors that are often beyond control, and far from guaranteed.

The Scale of the Problem

The 2017 World Workshop and the 2024 Academy of Osseointegration and American Academy of Periodontology (AO/AAP) consensus established the current case definition: peri-implantitis is a plaque-associated pathological condition occurring around an implant, characterized by inflammation in the peri-implant mucosa and subsequent progressive loss of supporting bone. The distinction from peri-implant mucositis is critical: mucositis is reversible, peri-implantitis is not.

What makes peri-implantitis particularly difficult is that it can progress silently. Patients often report no pain until significant bone loss has occurred. By the time radiographic changes are visible, the disease may already be advanced. This is why the AO/AAP 2024 consensus identified regular monitoring as the single most important modifiable factor in preventing catastrophic implant loss.

The risk factors are now well-established: history of periodontitis, smoking, uncontrolled diabetes, poor biofilm control, obesity, and implant malposition.

What the Long-Term Data Actually Shows

The evidence reveals a more nuanced picture than the headlines suggest.

Disease Resolution: The 60% Ceiling

Monje et al. (2025) published the most thorough systematic review of long-term surgical outcomes in Periodontology 2000. The review screened for studies with at least five years of follow-up and identified 17 qualifying long-term studies. The results:

  • Mean disease resolution rate: 58.6% (composite definition, where reported)
  • Progressive bone loss arrestment: 69.6%
  • Bleeding on probing resolution: 59.9%
  • Retreatment needed: 27.2% of cases
  • Implant survival: 88.6% (range: 75 to 100%)

Read those numbers carefully. The implant survives in nearly nine out of ten cases. But disease resolution, the actual goal of treatment, happens in only about six. And more than a quarter of patients need a second surgery.

The 7-Year RCT: Even Worse at the Extreme

Where the Monje review provides the aggregate, Isler et al. (2025) provides the controlled trial perspective. This 7-year randomized clinical trial, published in Clinical Oral Implants Research, followed 57 patients treated with reconstructive surgery using xenograft plus either concentrated growth factor or collagen membrane.

At 7 years, treatment success was achieved in only 23.1% of the CGF group and 30.8% of the CM group. Disease recurrence occurred in 34.6% and 30.8%, respectively. The authors described a clear tendency toward relapse over time. The only significant predictor of failure was baseline suppuration, with an odds ratio of 15.45.

A patient presenting with suppuration at the time of surgery was roughly 15 times more likely to fail treatment.

The Romandini Data: Predicting Who Loses the Implant

Romandini et al. (2023), in a retrospective study of 149 patients and 267 implants with a mean 7-year follow-up published in Clinical Oral Implants Research, provides the most detailed prognostic picture available. The implant loss rate was 19.9% over the observation period, with implant loss occurring after a mean of 4.4 years.

The strongest predictor was implant surface characteristics. Modified (rough) surfaces carried a hazard ratio of 4.5 for implant loss compared to turned (machined) surfaces. This is not a marginal difference. It is the difference between a 1% and a 63% chance of losing the implant within five years.

What Predicts Failure

Across the evidence, five factors consistently emerge as predictors of poor surgical outcomes:

  1. Residual pockets ≥6 mm after surgery. The Monje review found that the odds of disease recurrence were approximately 8 times higher when residual pathogenic pockets were present during follow-up. This is the single most actionable finding in the entire literature. If surgery does not achieve adequate pocket reduction, the patient is set up for recurrence.
  2. Modified (rough) implant surfaces. Gardelis et al. (2025) confirmed in their systematic review that rough surfaces were generally associated with higher recurrence rates and implant loss compared to smooth surfaces. Reconstructive approaches showed better outcomes than non-reconstructive ones, but surface characteristics remained a dominant factor.
  3. Baseline suppuration. Both Isler (OR 15.45) and Romandini (HR 2.7) identified suppuration at baseline as a significant negative predictor. When pus is present at the surgical planning stage, the odds of success drop dramatically.
  4. Advanced bone loss. Romandini found that baseline bone loss severity independently predicted implant loss (HR 1.2 per mm). The >60% bone loss threshold marks the point where outcomes become genuinely poor.
  5. Narrow keratinized mucosa (<2 mm). The Monje review identified this as a factor influencing disease recurrence. Soft tissue quality matters, not just around teeth but around implants.

What Predicts Success

The evidence is not all grim. Solderer et al. (2024), in a meta-analysis of 45 studies and 3,463 treated implants published in the International Journal of Oral Implantology, found that reconstructive surgical modalities had a significantly lower implant failure rate (1.0%) at 36 months compared to non-reconstructive modalities (8.0%).

Zhou et al. (2026), in a retrospective cohort of 406 implants across four surgical protocols, found an overall 54.7% treatment success rate at one year. The factors associated with success were telling: systemic antibiotic use (pre-operative OR 3.54, pre- and post-operative OR 4.49) and surgeon experience (OR 0.12, meaning experienced surgeons had dramatically better outcomes).

The Antibiotic Question

Should systemic antibiotics be prescribed with peri-implantitis surgery? The evidence points to a qualified yes, with important caveats.

Antonoglou et al. (2025), in a systematic review with meta-analysis published in the Journal of Clinical Periodontology, analyzed seven studies with 595 patients and 1,388 implants. Systemic antibiotics were found to be associated with:

  • Greater short-term treatment success (OR 2.33)
  • Increased bone level stability (OR 2.73)
  • Reduced bleeding on probing (OR 0.49)
  • Reduced suppuration on probing (OR 0.33)

However, the benefit was short-term only (1 to 2 years). No substantial long-term benefits were seen at 3 years or beyond. Furthermore, the benefit was confined to implants with modified surfaces (OR 4.10 for modified vs. 0.79 for turned).

The Supportive Therapy Pillar

Everything discussed so far assumes one critical condition: the patient is enrolled in supportive peri-implant care. Without it, the numbers cited do not apply.

Lee et al. (2026), in a retrospective multicenter study of 3,555 implants published in Clinical Oral Implants Research, demonstrated this directly. The 5-year survival rate was 98.8% for patients who received regular supportive periodontal therapy. This is the most modifiable risk factor in the entire peri-implantitis literature.

The Honest Summary

Peri-implantitis surgery is effective but not predictable. The best evidence available says that under supportive care, about 60% of patients achieve disease resolution long-term. Reconstructive approaches outperform access surgery. Systemic antibiotics help in the short term for modified-surface implants. Surgeon experience matters. Baseline suppuration and advanced bone loss are red flags. And above all, supportive maintenance is the difference between an implant that survives and one that does not.

References

  1. Monje A, Pons R, Ramanauskaite A, Castro A, Schwarz F, Chambrone L. (2025). Long-term surgical treatment outcomes of peri-implantitis. Periodontology 2000. DOI: 10.1111/prd.12643
  2. Isler SC, Soysal F, Ceyhanli T, et al. (2025). Long-Term Treatment Outcomes of Peri-Implantitis Reconstructive Therapy: 7-Year Survival and Success of a Randomized Clinical Trial. Clinical Oral Implants Research. DOI: 10.1111/clr.14466
  3. Solderer A, Paterno Holtzman L, Milinkovic L, et al. (2024). Implant failure and clinical and radiographic outcomes after surgical treatment of peri-implantitis: A meta-analysis. International Journal of Oral Implantology.
  4. Antonoglou GN, Papageorgiou SN, Payer M, Stavropoulos A. (2025). Do Systemic Antibiotics Offer Benefits to the Surgical Treatment of Peri-Implantitis? A Systematic Review With Meta-Analyses. Journal of Clinical Periodontology. DOI: 10.1111/jcpe.70021
  5. Lee D, Ahn S, Park JY, et al. (2026). Supportive Periodontal Therapy Improves Implant Survival in Patients With a History of Periodontitis. Clinical Oral Implants Research. DOI: 10.1111/clr.70103
  6. Romandini M, et al. (2023). Long-term outcomes and prognostic factors of surgical treatment of peri-implantitis: A retrospective study. Clinical Oral Implants Research.
  7. Gardelis P, Giannopoulou C, Stavropoulos A, Zekeridou A. (2025). Impact of implant surface modifications on long-term outcome of surgical peri-implantitis treatment: a systematic review. Frontiers in Dental Medicine. DOI: 10.3389/fdmed.2025.1661369
  8. Zhou W, et al. (2026). Treatment Outcome of Surgical Protocols for Peri-Implantitis: A Retrospective Cohort Study in a Specialised University Centre. Journal of Clinical Periodontology. DOI: 10.1111/jcpe.70115

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