Risk Stratification: Identifying High-Risk Patients Before Failure

Peri-implant disease isn't a random occurrence. It is a predictable disease.

The 2024 AO/AAP Consensus on Peri-Implant Diseases analyzed over 13,030 patients across 102 studies and identified exactly who's at highest risk and why.

If you are placing implants, you need to know these numbers. Because prevention starts before the osteotomy, and not after the disease develops.

The Scale of the Problem

61% of patients develop peri-implant mucositis within 10 years. 14% progress to peri-implantitis.

And by 20 years, peri-implantitis affects 22% of patients, which means one in five patients can be facing potential implant loss.

The exponential rise in implant placement means that peri-implant diseases are now an epidemic. However, the 2024 consensus highlighted the critical point that we can predict who is at the highest risk.

The Big Five Risk Factors That Predict Failure

The AO/AAP systematic review analyzed 102 studies. Five risk factors emerged as the strongest predictors:

1. History of Periodontitis (The #1 Predictor)

• Patients with past periodontitis are at higher risk of developing peri-implant mucositis
• Patients with active, untreated periodontitis have 3× the risk

What to do? Never place implants in patients with active periodontitis. Stabilize the disease first and keep them on a 3-month recall instead of a 6-month recall.

2. Smoking

The evidence:

What the research shows:

• Current smokers and those who quit less than 10 years ago have higher risk of peri-implant mucositis.
• Smoking damages the gum barrier and alters bacteria around implants

Clinical action: Smokers need more frequent recalls mostly every 3 months. Encourage cessation as the benefits don't really show up until 10+ years post-quit.

3. Uncontrolled Diabetes

The evidence:

• Identified as a potential risk indicator specifically for peri-implantitis
• Impairs wound healing and immune response

Clinical action: Always monitor recent HbA1c levels. Delay implant placement if glycemic control is poor. Focus on maintenance post-placement.

4. Obesity

The evidence:

• Identified as a potential risk indicator for peri-implant mucositis
• Creates pro-inflammatory state that affects peri-implant tissue health

Clinical action: This emerging risk factor requires more caution in obese patients.

5. Poor Biofilm Control

The evidence:

• Poor maintenance compliance is associated with highest peri-implantitis incidence.
• Poor microbial control is also listed as a key behavioral risk factor

Clinical action: It is mandatory for patients to understand the importance of oral hygiene maintenance to ensure long-term success.

Creating Patient-Level Risk Profiles

Based on the consensus, you can stratify patients into three categories:

Low Risk:

• No periodontitis history, non-smoker, good oral hygiene
• Recall: 6–12 months

Moderate Risk:

• Controlled periodontitis and ideally stable for over a year, a former smoker who quit 10 years ago, and a well-controlled diabetic
• Recall: 3–4 months

High Risk:

• Active or poorly controlled periodontitis, current smoker, uncontrolled diabetes, poor compliance
• Recall: 3 months or less

Site-Level Risk Factors You Control

The consensus also highlighted site-specific risks:

• Implant malposition that can be too facial or inadequate spacing
• Unfavorable prosthetic design can be due to cement retention or poor emergence profile
• Suboptimal soft tissue due to a lack of keratinized tissue

These are factors that you can control during treatment planning.

Documentation Essentials

Every implant case needs to have the following documentation prior to implant placement:

• Periodontal status at placement
• Smoking status and quit timeline
• HbA1c if diabetic
• BMI and metabolic health
• Oral hygiene assessment
• Recommended recall interval based on risk

This protects you medico-legally and ensures care continuity.

Final Takeaway

The 2024 AO/AAP Consensus gives us evidence-based risk profiles to predict peri-implant disease.

Over half of your implant patients will develop mucositis within 10 years. One in five will progress to peri-implantitis by 20 years. But these aren't random; they are predictable based on five key risk factors.

Identify high-risk patients before you place the implant. You can tailor recall intervals as per risk profiles. Focus on maintenance for those who need it most.

Prevention isn't just surgical technique; it is knowing who needs closer watching and acting systematically.

References

1. Wang HL, Avila-Ortiz G, Monje A, Kumar P, Calatrava J, Aghaloo T, et al. AO/AAP consensus on prevention and management of peri-implant diseases and conditions: Summary report. J Periodontol. 2025;96(6):519-45. Available from:
2. Galarraga-Vinueza ME, Pagni S, Finkelman M, Schoenbaum T, Chambrone L. Prevalence, incidence, systemic, behavioral, and patient-related risk factors and indicators for peri-implant diseases: An AO/AAP systematic review and meta-analysis. J Periodontol. 2025;96(6):587-633.
3. Kumar PS, Kan J, Galarraga-Vinueza ME, Lin GH, Monje A, Tavelli L, Stuhr S, Hsu YT, Li J, Tsigarida A, Dias D, Ganesan S, Yin S, Curtis D. Risk for peri-implant diseases and defects: Report of workgroup 1 of the joint AO/AAP consensus conference on prevention and management of peri-implant diseases. Clin Adv Periodontics. 2025 Jun;15(2):93-102.
4. Fiorellini JP, Mojaver S, Sarmiento H, Aghaloo T. Clinical translation of the 2024 AO/AAP Consensus on prevention and management of peri-implant diseases and conditions. Int J Periodontics Restorative Dent. 2025;45(4):1-23.