Suppurating Implant in a Smoker With Poor Glycemic Control
A 52-year-old woman attends for maintenance 6 years after a single implant replacing the maxillary right first premolar. She has a history of Stage III grade C periodontitis treated with non-surgical therapy and one surgical site 5 years ago; she smokes 12 cigarettes a day and her HbA1c is 8.6%. The implant has a 7-mm bleeding pocket on the palatal aspect, 2 mm of recession, suppuration on probing, and a periapical radiograph shows 3.5 mm of bone loss from the implant shoulder, with a 1-mm thread exposure. The adjacent tooth 14 has a 5-mm pocket and 30% bone loss. She reports no pain and asks whether the implant “can just be cleaned”. She has not attended maintenance for 18 months, and her plaque score is 48%.
1. What is the diagnosis and how do you assess whether the implant can be saved?
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Diagnosis: peri-implantitis around the maxillary right first premolar implant, with plaque-induced inflammation modified by smoking and poor glycemic control. The 7-mm bleeding pocket, suppuration, 3.5-mm bone loss, and 1-mm thread exposure exceed the threshold for mucositis. The adjacent 5-mm pocket and 30% bone loss indicate untreated or recurrent periodontitis, an important risk factor.
Salvageability assessment: I would check implant stability, pain, restoration integrity, cement status, occlusal contacts, and whether the bone defect is contained or circumferential. A CBCT can show defect morphology and whether the palatal bone wall is intact; a radiograph alone is limited. The patient’s ability to improve plaque control, stop smoking, and attend maintenance is decisive. I would also assess implant position and whether the restoration can be cleaned.
Prognosis: guarded but not hopeless. A contained defect with a stable implant and a motivated patient has a better chance than a circumferential defect with suppuration and continued smoking. I would not declare the implant failed on pocket depth alone.
2. Outline your non-surgical and surgical management, including how you would address the smoking and glycemic control.
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Non-surgical phase: reinforce oral hygiene with interdental brushes and a powered brush; disclose plaque; debride the implant surface with titanium or plastic instruments and an air-polishing device suitable for implants; avoid metal curettes that gouge the surface. Use chlorhexidine short-term as an adjunct, not as a substitute. Treat the adjacent periodontitis with scaling and root planing and reassess.
Systemic factors: refer for smoking cessation and coordinate with her physician about HbA1c; poor glycemic control impairs healing and increases recurrence. Explain that without risk-factor control, surgery is likely to fail.
Surgical phase: if non-surgical therapy does not resolve bleeding and suppuration, raise a flap, decontaminate the implant (air-abrasive, EDTA, possibly citric acid), and assess the defect. For a contained intrabony defect, consider guided bone regeneration; for a suprabony defect, implantoplasty may help, but it is difficult palatally and can weaken the implant. Reassess at 6–8 weeks before deciding. Maintenance every 3 months is part of treatment, not an optional extra.
3. Under what circumstances would you explant, and how would you plan replacement?
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Explant if: there is progressive bone loss despite non-surgical and surgical treatment, implant mobility, uncontrolled suppuration or pain, a non-restorable position, or failure of the patient to control risk factors and attend maintenance. A circumferential defect with loss of the palatal wall and a poor esthetic outcome would also favor removal.
Planning replacement: first establish periodontal stability and risk-factor control. Then assess bone volume and soft tissue with CBCT; the site may need guided bone regeneration or soft-tissue grafting. Consider whether an implant is the right choice at all: a cantilever or fixed dental prosthesis may be preferable if she cannot maintain implants. If an implant is planned, use a restorative-driven position, ensure cleansability, and agree on a 3-month maintenance schedule. Explain that replacement without behavior change risks repeating peri-implantitis, and document that discussion.