Air polishing in peri-implantitis: no extra pocket reduction over instrumentation

Air polishing has become a familiar part of non-surgical peri-implantitis therapy, often on the assumption that powders reach contaminated threads better than curettes and ultrasonics. This systematic review asked a precise question: in adults with peri-implantitis, does air polishing, used either as an adjunct to or as a replacement for non-surgical instrumentation, improve disease resolution and probing pocket depth (PPD) compared with instrumentation alone?

The authors searched MEDLINE, Web of Science, Scopus, EMBASE and CENTRAL up to July 2026. Randomized and non-randomized comparative studies were eligible only if the case definition required bleeding and/or suppuration on probing together with radiographic bone loss, which keeps mucositis cases out. PPD and bleeding on probing (BOP) were pooled with a random-effects model, with the therapeutic role (adjunct or replacement) as a pre-specified subgroup. The statistics were conservative: Hartung-Knapp-Sidik-Jonkman intervals and adjustment for clustering of implants within patients. Other outcomes were synthesized without meta-analysis, and certainty was rated with GRADE.

Fourteen studies were included, ten in the meta-analysis. At six months, the mean difference in PPD change was -0.03 mm (95% CI -0.38 to 0.31) when air polishing was added to instrumentation and +0.04 mm (95% CI -0.52 to 0.59) when it replaced instrumentation. There was no subgroup difference (p = 0.78) and heterogeneity was negligible (I² = 3.4%). No significant differences emerged at other timepoints or for BOP. Certainty was low for the adjunctive PPD result and very low for every other outcome.

The conclusion is restrained. Adding air polishing to conventional instrumentation did not show a clinically meaningful PPD benefit. As a replacement, the evidence is too imprecise to establish superiority, equivalence or inferiority: absence of proof, not proof of equivalence.

Clinical relevance: non-surgical therapy of peri-implantitis has modest results whatever the device, and this review gives no reason to expect air polishing to change that on its own. It can remain a tool for patient comfort or access, but it should not be sold to the patient as the factor that resolves the disease. Case selection, plaque control and timely surgical management remain the levers that matter. Well-designed trials with standardized endpoints are still needed.