Peri-implantitis: smoking, diabetes and lack of keratinized mucosa as causes

A clinical synthesis to guide prevention

The long-term success of implant-supported restorations remains a major challenge in the face of emerging peri-implant pathologies. This scientific synthesis, published in September 2026, evaluates the determining risk factors and contemporary preventive strategies based on the 2025 AO/AAP consensus, as well as a series of meta-analyses and systematic reviews published between 2023 and 2026.

The central objective of this work is to map the clinical vulnerabilities of the implant patient. To do this, the compiled data are based on a large sample of 13,030 patients, revealing a prevalence of 46% for peri-implant mucositis and 21% for peri-implantitis. The synthesis highlights the temporal evolution of the weighted incidence of peri-implantitis, calculated at 12% after 5 years, 14% at 10 years, and reaching 22% over a 20-year period.

The study analyses the impact of systemic and behavioural comorbidities, confirming the major influence of smoking (OR 2.27), diabetes (OR 2.31), and alcohol consumption (OR 2.07). It also examines surgical and prosthetic factors, notably the lack of keratinised mucosa (OR 2.78), in order to establish a prevention protocol based on periodontal stabilisation, three-dimensional planning, and personalised long-term maintenance.

Methodology of the synthesis

This work does not constitute a primary study, but a synthesis of secondary evidence documenting the risk factors and preventive strategies for peri-implant pathologies. The analysis is based on a critical review of data published between 2023 and 2026.

The methodological foundation is based on the following publications:

• The 2025 AO/AAP (American Academy of Periodontology) consensus regarding the prevention and management of peri-implant diseases.
• The 2025 AO/AAP meta-analysis on systemic, behavioural, and patient risk factors, integrating 102 studies for a global cohort of 13,030 patients.
• Complementary systematic reviews and meta-analyses, including notably the study by Mahardawi et al. (2023) on the influence of the lack of keratinised mucosa.
• The selection of regional publications (Uzbekistan) to enrich the clinical perspective.

The authors compiled the data from these syntheses to establish a hierarchy of clinical risks. The analysis focuses on the weighted incidence of pathologies, the odds ratios (OR) associated with environmental and systemic factors (smoking, diabetes, alcohol consumption), as well as variables related to prosthetic design and the three-dimensional position of the implants. The protocol of this review allowed for the extraction of progression indicators over follow-up periods of 5, 10, and 20 years.

Synthesis of risk factors and incidence

The data compiled in this synthesis review, relying notably on the 2025 AO/AAP consensus, allow for the precise quantification of the evolution of peri-implant pathologies over time. The weighted incidence of peri-implantitis progresses linearly with the duration of device function.

The analysis of systemic and behavioural risk factors reveals statistically significant correlations, illustrated by the following odds ratios (OR):

• Smoking: OR 2.27
• Diabetes mellitus: OR 2.31
• Alcohol consumption: OR 2.07

Impact of local and surgical factors

Beyond systemic parameters, the synthesised literature highlights the decisive influence of the mucosal environment and prosthetic design. A specific meta-analysis identifies the absence of keratinised mucosa as a major aggravating factor, with an OR of 2.78.

The authors of the review highlight several critical clinical elements that increase the risk of pathological progression:

• Periodontal history: The presence of active residual pockets weakens the peri-implant site.
• Three-dimensional positioning: A defect in implant planning compromises long-term maintenance.
• Prosthetic design: Contours that hinder access to daily hygiene promote plaque accumulation.
• Follow-up: Irregularity in supportive periodontal maintenance sessions is correlated with an increase in complications.

Towards targeted preventive management of peri-implant diseases

This synthesis of evidence, based on recent AO/AAP consensus work, clarifies the hierarchy of clinical risks. The weighted incidence highlights an inevitable progression of risk over time: 12% of complications at 5 years, reaching 22% after two decades of function. These data demonstrate that monitoring cannot be static; it must adapt to cumulative exposure to biological and mechanical stress factors.

The results highlight three major systemic vectors: smoking, diabetes, and alcohol consumption. In parallel, the absence of keratinized mucosa is confirmed as a critical predictive factor, justifying preventive intervention from the surgical planning phase. Contrary to a vision solely centered on the technical procedure, this analysis requires integrating the patient's metabolic management and prosthetic design facilitating hygiene as inseparable pillars of implant survival.

The weak point of this work lies in its nature as a secondary synthesis, aggregating data from heterogeneous protocols. This approach, although robust, remains dependent on the clinical variability inherent in the included studies. Nevertheless, it confirms that the paradigm shift towards personalized maintenance and prior periodontal stabilization is no longer optional.

Analysis of risk factors and prevention

This synthesis of evidence-based data, based on the 2025 AO/AAP consensus, identifies the main levers for controlling peri-implant diseases. The weighted incidence of pathologies increases with the duration of function, rising from 12% over a five-year period to 22% over two decades.

Concretely, for the practitioner:

• Rigorous pre-implant evaluation: Systematically integrate glycemic control, smoking cessation, and management of periodontal history from the planning phase.
• Prosthetic optimization: Prioritize a design that facilitates home hygiene and ensure an adequate three-dimensional implant position to limit bacterial retention zones.
• Personalized maintenance: Do not settle for standard follow-up; establish a lifelong maintenance protocol from the moment of placement, coupled with monitoring of the keratinized mucosa, a significant protective factor.

Technical glossary: Understanding peri-implant risks

Peri-implantitis: Inflammatory pathology of the tissues surrounding an implant, characterized by progressive bone loss and soft tissue inflammation, the cumulative incidence of which worsens with time in function.

Peri-implant mucositis: Reversible inflammation of the mucosa surrounding the implant, without associated bone loss, constituting a frequent precursor state in the implant population.

Keratinized mucosa: Keratinized gingival tissue essential for peri-implant health; its absence is identified as a significant clinical risk factor promoting the development of inflammatory pathologies.

Prosthetically driven 3D planning: Implant planning strategy aimed at ensuring an optimal three-dimensional position of the implant to allow for a prosthetic design that facilitates hygiene and long-term maintenance.

Supportive peri-implant care: Rigorous and individualized longitudinal follow-up protocol, essential for the durability of the treatment, the irregularity of which constitutes a major risk factor for pathological progression.

Cleansable restorative design: Design of emergence profiles and prosthetic architecture specifically studied to prevent plaque accumulation and ensure effective access to cleaning devices on a daily basis.

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