ModifiedWellpointPolicy 06-103

Management of Peri-Implant Defects

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This Dental Clinical Policy describes the clinical evaluation, documentation, and treatment approaches for peri-implant mucositis, peri-implantitis, and other inflammatory defects surrounding osseointegrated dental implants. It provides guidance for reviewing dental services and does not itself establish member-specific coverage or reimbursement.

Policy Summary

PayerWellpoint

PolicyManagement of Peri-Implant Defects

Policy CodePolicy 06-103

Change TypeMinor editorial revision

Effective Date01/01/2025

Last ReviewOct 29, 2024

Next Review DateN/A

Key ActionSubmit current, dated pretreatment radiographic images obtained within 12 months that include the complete view of the implant.

SourceLink

POLICY UPDATE CHANGES

The 2024 revision was identified as a minor editorial change to the description, clinical indications, criteria, and references, with intent unchanged.

6Treatment modalities listed

>5 mmDeep probing depth

12 monthsRadiograph recency

6-pointPeriodontal charting

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ModifiedWellpointPolicy 06-103

Management of Peri-Implant Defects

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Sign up for wellpoint Policy 06-103 alerts

Get alerted when Policy 06-103 changes without checking for updates manually.

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Policy Summary

PayerWellpoint

PolicyManagement of Peri-Implant Defects

Policy CodePolicy 06-103

Change TypeMinor editorial revision

Effective Date01/01/2025

Last ReviewOct 29, 2024

Next Review DateN/A

Key ActionSubmit current, dated pretreatment radiographic images obtained within 12 months that include the complete view of the implant.

SourceLink

POLICY UPDATE CHANGES

The 2024 revision was identified as a minor editorial change to the description, clinical indications, criteria, and references, with intent unchanged.

6Treatment modalities listed

>5 mmDeep probing depth

12 monthsRadiograph recency

6-pointPeriodontal charting

Clinical Evaluation and Treatment Criteria

Diagnostic evaluation

Clinical evaluation of a peri-implant defect may identify the following findings, with radiographic examination used to differentiate peri-implant mucositis from peri-implantitis.

Clinical findings: Swelling, redness, bleeding on probing, increased probing depth, soft tissue attachment, implant mobility, percussion sounds, or occlusion findings

The document presents these as findings used during clinical examination.

Inflammatory findings: Deep probing depth greater than 5 mm, bleeding on probing, and/or suppuration on probing> 5 mm for deep probing depth

Loss of supporting bone usually forms a circumferential crater defect.

Diagnostic imaging: Radiographic examination is used to differentiate peri-implant mucositis from peri-implantitis and should include the complete implant view when submitted for review.Current dated pretreatment image within 12 months

This is a clinical and submission consideration, not an explicit coverage determination.

Treatment modalities

Treatment may be surgical or nonsurgical and should focus on infection control, implant-surface detoxification, and regeneration of lost support when appropriate.

Treatment approaches: Systemic antibiotics alone; mechanical debridement with or without systemic antibiotics; mechanical debridement with or without localized drug delivery and chlorhexidine oral rinses; mechanical debridement with laser decontamination; surgical debridement; or surgical debridement with guided bone regeneration for bony and soft-tissue defects.

The listed modalities are examples and are not stated as an exhaustive list.

Factors affecting peri-implant disease

Factors that may influence the peri-implant environment and disease management include:

Patient-related factors: Systemic diseases such as diabetes or osteoporosis and prior dental history including periodontitis

Social factors: Inadequate oral hygiene, smoking, or drug abuse

Parafunctional habits: Bruxism or malocclusion

Anatomic and iatrogenic factors: Inadequate keratinized mucosa; faulty restorations; excess cement following restoration delivery; components that are not fully seated or connected; or loose components

Coding and Diagnostic Requirements

CDT including but not limited toCDT

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. This procedure is not performed in conjunction with D1110, D4910 or D4346.

Diagnostic radiograph recency

RecencyCurrent diagnostic pretreatment radiographs obtained within 12 months

DatingImages must be dated

Required viewImages must include the complete view of the implant

Deep probing depth

ThresholdDeep probing depth greater than 5 mm

Associated findingsBleeding and/or suppuration on probing may also be present

Supporting-bone finding

Documentation to Submit

Documentation Required

Submit complete, current pretreatment imaging

Submit current, dated diagnostic pretreatment radiographic image(s) obtained within 12 months that include the complete view of the implant. Clinical chart notes, intra-oral photographs, current dated 6-point periodontal charting including implant mobility, and history of periodontal therapy may also be required.

Policy Background

Peri-implant diseases are inflammatory conditions affecting the soft and hard tissues surrounding dental implants. Bacteria may accumulate at the base of an implant below the gingival line, compromising gingival tissue and potentially contributing to deterioration of the supporting bone if not identified and managed early. Peri-implant mucositis is limited to soft-tissue inflammation without bone loss, while peri-implantitis includes inflammation with deterioration of the bone supporting the implant. Peri-implant defects involve an inflammatory process affecting the tissues surrounding an osseointegrated implant and may require infection control, improved oral hygiene, removal of diseased tissue, antibiotics, or reconstructive and regenerative treatment.

Key Definitions

Peri-implant mucositis

ConditionInflammation around the soft tissues of a dental implant

Bone lossThere are no signs of bone loss

Clinical significancePeri-implant mucositis may precede peri-implantitis

Peri-implantitis

ConditionInflammation around the soft tissue of a dental implant

Bone involvementDeterioration of the bone supporting the dental implant is present

ClassificationPeri-implantitis is distinct from peri-implant mucositis, which has no signs of bone loss