Rethinking Peri-implantitis: Etiologic Heterogeneity, Tailored Treatment, and Long-Term Disease Control

Peri-implantitis is a biofilm-mediated inflammatory disease with substantial etiologic heterogeneity and variable treatment outcomes. Its development appears to reflect the interaction of microbial dysbiosis and host susceptibility with local anatomical, implant-related, prosthetic, and maintenance-related factors, some of which may originate during implant therapy. This narrative review summarizes current evidence on factors associated with disease onset and progression and examines their implications for prevention, diagnosis, and treatment planning. Particular attention is given to stepwise therapy, including initial non-surgical disease control, correction of modifiable factors, implant-surface decontamination and preservation, indications for surgery, defect-oriented reconstructive and resective approaches, and the selective use of implantoplasty. Long-term outcomes are also considered in relation to residual disease activity, recurrence risk, and supportive peri-implant care. Current evidence supports an individualized, risk-based approach in which treatment intensity is adapted to disease severity, defect configuration, surface exposure, and patient-specific susceptibility. Treatment success can be maintained over time only when control of inflammation and progressive bone loss is sustained through structured supportive peri-implant care (SPIC).