CurrentAnthemPolicy 06-103

Management of Peri-Implant Defects

Provides clinical guidance on diagnosis, evaluation, and treatment options for peri-implant defects (peri-implant mucositis and peri-implantitis), and lists relevant CDT procedure codes for informational purposes. It also specifies documentation/submission requirements for dental review.

Policy Summary

PayerAnthem

PolicyManagement of Peri-Implant Defects

Policy CodePolicy 06-103

Change TypeRevised (annual review)

Effective DateJan 1, 2024

Next Review Date

Key ActionProvide current (within 12 months), dated, diagnostic pretreatment radiographic images that include the complete view of the implant as part of submission for management review.

SourceLink

POLICY UPDATE CHANGES

Policy status listed as Revised with last review date 10/25/2023 and publish date 01/01/2024 (annual review).

6Listed treatment modalities

6Relevant CDT procedure codes listed

>5 mmProbing depth threshold for peri-implantitis

Policy overview

Peri-implant defects (peri-implant mucositis and peri-implantitis) are inflammatory processes affecting the soft and hard tissues surrounding osseointegrated dental implants. Management focuses on infection control, implant surface detoxification, and regeneration of lost support via surgical or nonsurgical approaches. Treatment choice depends on clinical signs, radiographic bone loss, and contributing patient or iatrogenic factors. Provides clinical guidance on diagnosis, evaluation, and treatment options for peri-implant defects (peri-implant mucositis and peri-implantitis), and lists relevant CDT procedure codes for informational purposes.

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Diagnostic, documentation, and treatment highlights

Diagnostic Criteria for Peri-Implant Defects

Peri-implant defects are diagnosed through clinical exam and radiographic evaluation. Diagnosis criteria include:

Clinical and radiographic findings: Clinical signs such as swelling, redness, bleeding on probing, increased probing depth, soft tissue attachment loss, implant mobility, percussion sound(s), and occlusion
Probing depth: Signs of deep probing depth (> 5 mm), bleeding and/or suppuration on probing> 5 mm
Probing depth threshold for peri-implantitis
Radiographic evidence to differentiate peri-implant mucositis from peri-implantitis (loss of supporting bone, circumferential crater defects)

Submission / Documentation Requirements for Management

Submissions for review must include:

Radiographic images: Current (within 12 months), dated, diagnostic, pretreatment radiographic image(s) that include the complete view of the implantwithin 12 months
Radiograph recency required for submission
Clinical chart notes
Intra-oral photographs
6-point charting: Current dated 6-point charting including implant mobility

Treatment Modalities (accepted options)

Treatment options can be surgical or nonsurgical and include, but are not limited to:

Systemic antibiotics: Administration of systemic antibiotics alone
Mechanical debridement ± systemic antibiotics: Mechanical debridement with or without systemic antibiotic treatment
Mechanical debridement ± local delivery: Mechanical debridement with or without localized drug delivery and chlorhexidine oral rinses
Mechanical debridement + LASER: Mechanical debridement combined with LASER decontamination

Factors Influencing Peri-Implant Disease

Peri-implant disease can be influenced by one or more of the following factors:

Patient-related systemic diseases (e.g., diabetes, osteoporosis) and prior dental history (periodontitis)
Social factors: inadequate oral hygiene, smoking, drug abuse
Parafunctional habits: bruxism and malocclusion
Mucosal factors: Presence of inadequate keratinized mucosa due to disease process
Iatrogenic factors: faulty restorations, excess cement, components not fully seated/connected, loose components

Documentation and submission requirements

Documentation Required

Submit diagnostic radiographs

Provide current, dated, diagnostic pretreatment radiographic image(s) that include the complete view of the implant as part of the submission for management review. Images must be no older than 12 months from the date of submission.

Radiographs must be current (within 12 months)
Images must be dated
Include the complete view of the implant (full implant view)
Pretreatment diagnostic radiographs

Documentation Required

Provide clinical records and imaging

Include clinical chart notes and supporting clinical documentation when submitting a case for peri-implant defect management. Provide intra-oral photographs, current dated 6-point periodontal charting that documents implant mobility, and the patient’s history of periodontal therapy when requested.

Clinical chart notes
Intra-oral photographs
Current dated 6-point charting including implant mobility
History of periodontal therapy (may be required)

Relevant procedure codes (informational)

Informational CDT Procedure Codes (applicable to document)mixed

D4245	Apically positioned flap
D6100	Implant removal, by report
D6101	Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure
D6102	Debridement and osseous contouring of a peri-implant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure
D6103	Bone graft for repair of peri-implant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration
D6081	Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure. Not performed in conjunction with D1110, D4910 or D4346.

Supporting literature

Multiple peer-reviewed references support the etiopathogenesis and treatment approaches for peri-implant defects, including classic and contemporary studies: Albrektsson 1988; Berglundh 2002; Renvert 2008; Schwarz 2006, 2008; and additional clinical and experimental reports cited in the guideline.

Key Thresholds and Stats

Probing depth indicating peri-implantitis> 5 mm

Radiograph recency for submissionwithin 12 months

Listed treatment modalities6

Relevant CDT procedure codes listed6

Probing depth threshold for peri-implantitis>5 mm

Definitions

Peri-implant defects: An inflammatory process affecting the soft and hard tissues surrounding an osseointegrated dental implant, similar microbiology to periodontal disease, associated with loss of supporting bone, bleeding on probing, and occasionally suppuration.

Generally accepted standards of dental practice: Standards based on credible scientific evidence in peer-reviewed dental literature, specialty society recommendations, views of recognized dentists in the clinical area, and other credible sources.