A Failing Implant in a Periodontally Susceptible Patient: Treat or Remove?

The diagnosis is peri-implantitis, not peri-implant mucositis. Mucositis is reversible inflammation confined to the soft tissue, with bleeding and possibly suppuration but no progressive bone loss beyond the initial remodeling. This patient has a 9-mm bleeding and suppurating pocket plus approximately 50% radiographic bone loss, which establishes bone involvement. The history of treated Stage III periodontitis and irregular maintenance are major risk indicators. The 1-mm band of keratinized mucosa may complicate plaque control, but it is not by itself diagnostic.

I would remove the prosthesis temporarily or verify that it can be removed to examine the abutment and clean any residual cement; a supragingival margin makes excess cement less likely but does not exclude it. I would probe circumferentially, record bleeding and suppuration, check mobility, and obtain a periapical radiograph with a long-cone technique. I would also assess the opposing dentition and occlusion. The key distinction is radiographic bone loss over time; a single radiograph without a baseline is less informative, but the combination of deep probing, suppuration, and 50% loss is sufficient to treat as peri-implantitis.

I would start with nonsurgical management: remove the crown and abutment if possible, debride the implant surface with titanium or carbon-fiber instruments, clean the prosthesis and abutment, and reinforce hygiene. Adjunctive chlorhexidine or local antimicrobials may be used, but evidence for lasting benefit is limited. Systemic antibiotics are not routine and should be reserved for acute infection or specific clinical situations. I would reassess in 4–6 weeks; if bleeding, suppuration, and deep probing persist, surgical access is needed.

Surgical options include flap debridement with surface decontamination, possible implantoplasty, and either a resective or regenerative approach depending on defect morphology. A contained defect may be considered for regeneration, but advanced bone loss and a noncontained defect make resection or explantation more realistic. I would recommend explantation if the implant is mobile, fractured, positioned so that hygiene is impossible, has uncontrolled infection, or has bone loss that makes long-term function and esthetics unlikely. Because the implant is not mobile and the prosthesis is intact, a treatment attempt is reasonable if she accepts the uncertainty and commits to maintenance. The threshold is not a single pocket depth; it is the combination of remaining bone, defect shape, restorability, and patient compliance.

I would be explicit that “deep cleaning” alone is unlikely to resolve peri-implantitis with 50% bone loss and suppuration. I would explain that mechanical debridement is necessary but often insufficient, that no surface-decontamination method has emerged as a definitive gold standard, and that surgical access improves the ability to clean the implant but still does not guarantee bone gain or implant survival. I would present the options in plain language: nonsurgical debridement with close monitoring; surgical debridement with or without regenerative or resective procedures; and explantation with later reconstruction. I would give a realistic prognosis rather than a promise.

If she insists on nonsurgical treatment only, I can agree to a time-limited trial with clearly defined review points, provided she understands the risk of progression and the possibility of sudden failure. I would document her preference, the alternatives discussed, and the fact that she declined surgery for now. I would also address maintenance; without regular supportive care, any treatment is likely to fail. The ethical judgment is to respect autonomy while avoiding complicity in a plan that has little chance of controlling the infection. If suppuration, pain, mobility, or rapid bone loss develops, I would recommend explantation promptly.