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Journal of Oral Science & Rehabilitation 46 Volume 2 | Issue 4/2016 D e f i n i t i o n o f p e r i i m p l a n t i t i s logical condition, focusing on the bacterial load of the implant surface and the subsequent ap- pearance ofa soft-tissue inflammatoryreaction adjacent to dental implants that sometimes re- sulted in loss ofsupporting bone.11, 24, 25 Like peri- odontitis,theetiopathogenesisofperiimplantitis was shownto betriggered bybacterialinfection that activates a cytokine cascade, leading to in- flammatory bone loss.7 “Periimplantitis” became an accepted term in the consensus report from the 1st European Workshop on Periodontology in 1993.26 It has been described as an irreversible inflammatory destructive reaction around implants infunction that results in loss of supporting bone.26 The 6th EuropeanWorkshop on Periodontologypresen- ted a modified definition, not only to acknow- ledgethatperiimplantitisisatreatablecondition, but also to include the collective term of “peri- implant disease” for both periimplant mucositis and periimplantitis.10 In orderto improvethe qualityofresearch on periimplantdiseases,the7th EuropeanWorkshop on Periodontologyrecommendedthe use ofun- equivocal case definitions: changes in the level ofcrestalbone and presence ofBOPand/orSUP, with orwithout concomitant deepening of peri- implantpockets.8 Finally,theAmericanAcademy of Periodontology in 2013 defined “periimplan- titis” as an inflammatory reaction associated with the loss of supporting bone beyond the initial biological bone remodeling around an im- plant in function.7 The extent and severityofperiimplant disea- ses have been rarely reported.27, 28 Froum and Rosen proposed a combination of BOP and/or SUP,PPDandextentofradiographicMBLaround the implant to classify periimplantitis into early, moderateoradvanceddiseasecategories.28 Like- wise, Deckeret al. proposed a prognosis system based on the diagnosis for each category fol- lowing the Kwok and Caton prognosis classifi- cation for natural dentition.27 In their study, the authors stated that PPD, extent of radiographic MBL,presenceofSUPandimplantmobilitywere found to be the most critical factors for catego- rizing cases as having a favorable, questionable, unfavorable or hopeless prognosis.27 Recently,Albrektssonetal.modifiedthecon- cept of periimplantitis as a loss of bone sur- rounding an implant as a clinically unfavorable, disbalanced foreign-body reaction, specifically statingthatosseointegrationisaprocesswhere- by bone reacts to the dental implant by forming a calcified structure adjacent to it.22 Indeed, at times, this foreign-body reaction may actually result in osteoclastic activity that may destroy the supporting bone.22 The authors believe that the term “periimplantitis” is quite appropriate, because it is not a primary disease, but a com- plication of a clinically unfavorable, disbalanced foreign-body reaction that is the starting point of the pathological process and consequent tissue sequelae.22 Currently, as foreseen by the consensus of the 7th European Workshop on Periodontology,8 it is assumed that the infection itself is always caused by plaque and its products; However, numerous risk factors are recognized as being specificallyassociatedwith periimplantitis, such as surgical- or prosthetic-related factors,19, 20, 29 implant characteristics,21 smoking30 and host response.30, 31 D e f i n i t i o n o f p e r i i m p l a n t i t i s w i t h c l i n i c a l a n d r a d i o g r a p h i c d i a g n o s i s Thirty-one manuscripts (Table 2) were selected anddatawereextracted.Informationsfrom1,711 patientswith5,432implantswereanalyzed.The term “periimplantitis” has generally been used to describe any implant with varying degrees of bone loss, and a clear definition was either not presented or was extracted directly from the terminology. Four main characteristics have been used to define “periimplantitis”. Interestingly, all of the authors consider BOP and SUP as indicators of periimplantitis. This approach considers purely plaque- and foreign-body-induced peri- implantitis, where an inflammatory response is oftentriggeredbythebiofilmoritsproductsand/ or foreign substances, such as residual cement. Moreover, 22 studies clearly reported PPD as a crucialparameterfordeterminingperiimplantitis. No study considered PPD < 3 mm as indicative ofperiimplantitis.Whilethevast majority(64%) of the studies defined PPD = 3–5 mm as indicative of periimplantitis, the remaining 36% consideredPPD>5mmasthereference(Fig.2). A radiographic MBL ≥ 0.5–1 mm, > 1–2 mm, > 3–4 mm and ≥ 5 mm, taking prosthesis delivery as baseline, was considered as defining periimplantitis in 15%, 45%, 35% and 5% ofthe studies, respectively (Fig. 3). As such, it was speculated that a radiographic MBL < 1 mm should be considered as physiological bone remodeling. Table 2 Original articles included in the systematic review on the clinical diagnosis of peri- implantitis.