Smoking and the incidence of peri-implantitis


With the increasing use of dental implants as a restorative option there is a greater focus on peri-implantitis. Peri-implantitis is a characterised by inflammation of the peri-implant mucosa and progressive loss of supporting bone with a recent review (Dental Elf – 24th Oct 2022) indicating a patient-level prevalence of 20% (95%CI; 16.6% to 23.7%). While smoking is recognised as a risk factor for periodontal disease evidence for smoking as a risk factor for peri-implantitis is unclear.

The aim of this review was to evaluate the influence of smoking on the incidence of peri-implantitis.


A protocol was registered with the PROSPERO database. Searches were conducted in Medline/PubMed, Scopus Embase, ISI Web of Science, OpenGrey and the Grey Literature Report ( Prospective cohort studies that evaluate the incidence of peri-implantitis in smoker and non-smokers patients aged 18 years and above were considered. Two reviewers independently selected studies extracted data and assessed risk of bias. A modified version of the Newcastle–Ottawa scale (NOS) was used to assess risk of bias with the NOS being converted to Health Research and Quality (AHRQ) standards to categorise the studies as good, fair, and poor. Disagreements were resolved by discussion and consensus.  The GRADE approach was used to assess the certainty of evidence.


  • 6 prospective cohort studies involving a total of 762 patients (1,959 implants) were included.
  • Studies were conducted in Belgium, China, Germany, Italy, Spain and Switzerland between 2003 and 2021.
  • 5 studies were conducted in academic setting, and one is academic and private practice.
  • 4 studies were assessed as good and 2 as fair using AHRQ standards.
  • 4 studies reported peri-implantitis at patient levels with ranges from 1.85% to 32.07%.
  • 5 studies reported peri-implantitis at implant level ranging from 0.84% to 14.6%.
  • Meta-analyses showed an association between smoking and the risk of peri-implantitis at
    • Patient level (5 studies) risk ratio (RR) = 2.08 (95%CI; 1.17 to 3.71).
    • Implant level (5 studies) RR = 2.04 (95%CI; 1.46 to 2.85).
  • The GRADE certainty of evidence was assessed as moderate at patients and implant level.


The authors concluded: –

Moderate certainty evidence suggests that smoking is associated with peri-implantitis compared to non-smoking at the patient and implant levels. These results should be interpreted with caution due to the limited information on confounding factors in the included studies.


The authors registered a protocol for the review and searched a good range of databases with no language restrictions. Only prospective cohort studies were included with follow-up times ranging from 1 to 10 years and there was a lack of information on peri-implantitis at different time points with almost all the studies being conducted in an academic setting. Sample sizes ranged from 22 to 407 patients with only two studies involving 100 or more patients.  The authors highlight that smoking was not the main focus of the included studies so smoking activity was self-reported and level of exposure was only reported in one study. While the findings indicate an increased risk of peri-implantitis in smokers this is based on a small number of observational studies so the certainty of evidence should start as low using the GRADE approach where the quality of the studies is sufficient to uprate this to moderate is a matter for debate. While it would be unethical to conduct a randomised trial high quality prospective cohort studies of appropriate size are needed using more accurate methods of smoking assessment and proper consideration of other potential confounders and reporting of peri-implantitis at regular time points.


Primary Paper

Reis INRD, do Amaral GCLS, Hassan MA, Villar CC, Romito GA, Spin-Neto R, Pannuti CM. The influence of smoking on the incidence of peri-implantitis: A systematic review and meta-analysis. Clin Oral Implants Res. 2023 Jun;34(6):543-554. doi: 10.1111/clr.14066. Epub 2023 Mar 28. PMID: 36939434.

Review protocol on PROSPERO

Other references

Dental Elf – 24th Oct 2022

Peri-implantitis – How common is it?

Dental Elf – 22 Jan 2014

Review suggests that smoking may have a harmful effect on peri-implant bone loss

Dental Elf – 14th Oct 2015

Dental implant failure risk higher in smokers finds review


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