Chlorhexidine (CHX), a bisbiguanide antiseptic, is generally considered the gold standard as part of post-operative care following periodontal and peri-implant procedures owing to its broad-spectrum antibacterial action, and antiplaque activity. It is bacteriostatic at lower, and bactericidal at higher concentrations. While 0.12% CHX is commonly used, studies have shown that 0.2% is also clinically effective. CHX mouthwash (in concentrations of 0.12%– 0.2%) and localized application of CHX chips are recommended over CHX gels for periodontitis. Warm salt water rinses are considered an effective alternative to CHX during minimally invasive procedures, predominantly because of the potential side effects that have been reported post-administration of CHX. The combined action of xylitol, lysozyme, and sea salt has shown to be therapeutic in combating calculus formation. Rinsing with water alone, however, has not shown any adjunctive therapeutic effects. CHX has a positive effect on probing depth (PD) and clinical attachment level (CAL) reduction. Adverse effects of CHX include, but are not limited to, discoloration and altered taste. Effect of CHX on improvement in clinical parameters around implants lacks empirical evidence. When soaked in CHX, titanium implant surfaces have shown substantivity (ability to adsorb CHX and release over time) with rough surfaces (such as sandblasted-acid etched or blast-treated) exhibiting more adsorption than smoother surfaces (such as machined or acid-treated) due to a larger surface area. ^, The adsorption of CHX, rather than the desorption, is responsible for the antiplaque activity. However, the cytotoxic effects and potential effect on biocompatibility around implant surfaces must be kept in mind before routinely employing the usage of CHX around implant surfaces. ^, It is to the clinician’s discretion to weigh the pros and cons of CHX as an adjunct therapy.

Recently, concerns have been raised regarding CHX cytotoxic effects. In vitro studies reveal that, at higher concentrations, CHX is associated with increased reactive oxygen species, DNA damage, disruption in mitochondrial activity, inhibition of protein synthesis, and suppression in cell proliferation. At lower concentrations (0.0012%– 0.004%), CHX has been shown to not affect gingival fibroblast proliferation or morphology or inhibit bacterial growth, indicating that even very diluted solutions can be clinically effective. CHX appears to penetrate biofilms more efficiently at lower concentrations (0.05%). CHX may affect early wound healing in periodontal regeneration due to its effect on gingival fibroblasts, endothelial cells, and alveolar osteoblasts. Understanding these effects are crucial for developing safer clinical practices to minimize CHX-related toxicity.

Several studies have shown that using a mouthrinse with essential oils (EOs), alongside regular brushing and flossing, effectively reduces plaque and gingivitis, shifting the oral microbiome to a healthy equilibrium. EO includes, but not limited to, eucalyptus, menthol, methyl salicylate, and thymol. EO-based mouthrinses may promote oral health by inhibiting periodontal bacteria and improving clinical parameters. However, these mouthrinses are particularly beneficial for patients with mild periodontitis. Oral antiseptics with EO have demonstrated a reduction in viral titer in saliva for up to 30 min following oral rinse. Another study found that EO mouthrinse was at least as effective as dental floss in managing interproximal gingivitis.

Herbal mouthrinses are commonly employed for its enhanced antimicrobial properties, wound healing, and reduction in post-operative pain. Anaerobic bacteria, such as Streptococcus mutans , Actinomyces viscosus , Streptococcus pyogenes , Porphyromonas gingivalis , and Bacteroides fragilis , showed considerable decrease upon single use of such oral rinses. In addition, these products have also been reported to have anticancer properties, enhanced-wound healing, analgesic properties, and biocompatibility as compared to CHX. Although these agents have anti-inflammatory and anti-nociceptive properties, there is a lack of long-term prospective clinical trials, and hence further research is needed to assess its effects on biofilms and its role in managing periodontitis. Nevertheless, these herbal mouthrinses may act as a short-term beneficial adjunct to conventional periodontal mechanical debridement procedures. Currently, most of these products lack American Dental Association (ADA) seal and thus, the routine usage of these mouthrinses are not recommended.

Non-surgical periodontal treatments are commonly employed as prophylactic or therapeutic treatment modalities for reducing bacterial plaque, biofilm, and calculus, thereby reducing the subsequent inflammation. Oral prophylaxis is routinely performed bi-annually to maintain a state of clinical gingival health and to prevent new onset of disease process. If a disease process ensues, scaling and root planing (SRP) is employed as first-line of treatment to control the inflammatory process and to reduce bacterial load before proceeding to surgical periodontal treatment. After periodontal treatment is completed, patients are usually on a regular periodontal maintenance regimen to prevent further progression or recurrence of the disease process. The aforementioned non-surgical regimens usually comprise of supragingival/subgingival scaling combined with strict reinforcement and supervision of oral hygiene. Based on classical periodontal literature, curettes and ultrasonic instruments are equally effective in removing calculus, though neither of them offers complete calculus removal despite the initial PDs. There are negotiable differences, both of clinical importance in calculus removal, or in the level of residual endotoxins, between ultrasonics and curettes, irrespective of the amount of strokes or number of episodes of instrumentation. As PD increases, the efficiency of complete calculus removal drastically reduces; hence, surgical periodontal treatment is a preferred treatment option when PDs are more than 5 mm, for better access to subgingival calculus. ^, In addition, when considering exposed implant fixtures, decontamination of the surface without damaging it is crucial compared to root surface modifications. Thus, there is a significant need for better mechanical and/or chemical debridement tools specifically designed for peri-implant sites. Similarly, the efficacy of patient compliance with recommended periodontal, as well as recall/maintenance program is well-documented. Classic studies have reported that as long as the patient gets periodontal maintenance therapy every 3 mo, the role of home care for maintenance of PDs and CALs is not critical. Nonsurgical therapy is the primary approach for preventing, as well as treating peri-implant inflammation. However, unlike natural teeth, where some of the diseased cementum is removed during debridement, care has to be taken to preserve the implant surface. Although limited, there is some evidence to support the effectiveness of patient compliance with peri-implant maintenance as well. However, maintaining implant supported dentition is significantly more costly and not as predictable compared to maintaining a dentition with teeth that have reduced periodontium due to history of periodontal disease.

Periodontal armamentarium has been developed to implement effective non-surgical peri-implant treatment around titanium implant devices. These prophylactic methods have varying effects on implant surface roughness. Ultrasonic scalers, stainless steel and titanium curettes, and air jet polishing tend to increase surface roughness and may cause damage. In contrast, rubber cup and brush polishing, along with Teflon, plastic curettes, and plastic tip scalers generally maintain the implant surface with minimal alteration. Abrasive rubber cups enhance implant surface smoothness, making them the most favorable option for preserving implant integrity during maintenance procedures. Various types of ultrasonic instrumentation and curettes are used for non-surgical debridement, each with advantages and drawbacks. Plastic curettes are the most fragile and ineffective, potentially leaving debris that could worsen peri-implant disease. Steel curettes, due to their hardness, can damage implant surfaces and should be used cautiously. ^, Titanium curettes, having a hardness similar to implants and comparable strength to steel, cause less damage but may be less effective at removing calculus. Carbon-fiber and Teflon curettes are gentler on the implant surface and less likely to cause damage, though they are less efficient at calculus removal. Carbon-fiber curettes are also more prone to breaking, while Teflon curettes are often recommended alongside air-abrasive systems. ^, Additionally, ultrasonic tips coated with poly-ether-ether-ketone, a durable plastic with a stainless steel core, offer an effective option for removing calculus and biofilm from implants. Despite their polishing effect and minimal damage to the implant surface, plastic-coated scalers can leave small amounts of plastic residue behind. Clinicians must be careful to avoid pull strokes that create vertical grooves on the implant surface, as these can encourage harmful tissue growth.

Minocycline (1 mg) is a broad spectrum antibiotic that works by binding to the 30S ribosomal subunit and inhibiting protein synthesis within the bacterial cell wall. ^, The average half-life of a pharmacologic agent in the gingival crevicular fluid (GCF) is approximately 1 min, due to the constant replacement of the fluid around 40 times per hour. ^, However, hydrolysis of the minocycline microspheres in the GCF yields a sustained release of approximately 300 μg/mL of minocycline in the gingival sulcus with clinical effects lasting for about 14 d, which is more than the minimum inhibitory concentration for periodontopathic bacteria. ^,, Minocycline is also clinically detectable in saliva for an average of 2 w.

Minocycline microspheres, when used as an adjunct to SRP, showed considerable reduction in all clinical parameters, including PI, GI, PD, and CAL compared to SRP alone. ^, Similar results were obtained even when 2% minocycline gel was used as an adjunctive to SRP. ^, Minocycline leads to a reduction in the red complex bacteria, spirochetes, Fusobacterium nucleatum , and Prevotella intermedia and short-term reduction in interleukin (IL)-1 levels in GCF. Minocycline also had an enhanced clinical outcome in smokers than in non-smokers.

Similar to periodontitis, adjunctive use of minocycline microspheres with non-surgical or surgical debridement of peri-implantitis resulted in improved clinical outcomes, radiographic bone fill, and inflammation control (reduction in IL-1β and IL-10), over a year, particularly in moderate-depth lesions (5– 6 mm). Locally administered minocycline may augment peri-implantitis defect resolution through both antibacterial and anti-inflammatory effects, as evidenced by reduced cytokine levels locally and systemic markers, such as C-reactive protein and IL-1, in related studies. Minocycline also effectively reduced key periodontal pathogens, with the greatest impact on Aggregatibacter actinomycetemcomitans , lasting up to 1 y. The microbiologic effects persisted for up to 6 mo, consistent with findings from other studies using minocycline for peri-implantitis treatment. However, no significant changes were found in gingival recession or plaque scores. Adjunctive minocycline microspheres with non-surgical mechanical debridement have also shown enhanced clinical benefit for peri-implantitis in smokers, and in patients with type-2 diabetes mellitus. However, a recent systematic review also yields conflicting results on the use of local antimicrobial therapy and support systemic antimicrobial therapy for management of peri-implantitis.

A pharmacotherapeutic form of 2.5 mg CHX chip made of a polymerized gelatinous base, improves the periodontal health by decreasing PD and BOP as an adjunct to SRP. The clinical effects are more noticeable 3 mo after CHX placement. Similar effects on BOP and clinical parameters were observed with repeated applications of CHX chips or gel against peri-implant mucositis and peri-implantitis. CHX has a depleting effect on the prostaglandins, metalloproteinases, and pathogenic microorganisms found in the GCF. However, CHX chips do not have much clinical effect when used as adjunct to periodontal maintenance therapy. There are also reports of a localized traumatic effect on the mucosa, which when combined with traumatic toothbrushing, can lead to localized gingival recession in the area.

Doxycycline is a broad spectrum antibiotic that acts through the inhibitory effect on collagenases, matrix metalloproteinases (MMPs) in GCF and interfering with osteoclast function. Topical application of 10% doxycycline hyclate gel as an adjunct to SRP shows a higher reduction in PD and CAL as opposed to SRP alone. When used as an adjunct to periodontal regeneration of intrabony defects, it leads to reduction in inflammation characterized by improvement in BOP, soft tissue healing and reduction of pro-inflammatory markers, such as IL–1β, MMP-8, and MMP-9. Doxycycline lowers anaerobic bacterial count with a reduced probability of resistance. In diabetic patients, systemic doxycycline with SRP improves gingival inflammation but does not prevent ongoing periodontal tissue loss. Another randomized controlled trial has also showed increase in IL-10, decrease in periodontal pathogens and reduction in HbA ₁ c levels 3 mo after local 20% doxycycline administration in type 2 diabetics. There is also a modest improvement in clinical parameters reported in smokers with periodontitis. By the virtue of its osteogenic and broad spectrum activity, doxycycline as an adjuvant has also shown to reduce the markers of periodontal disease in cases of peri-implantitis. Doxycycline powder is also used adjunctive to surgical regenerative treatment of peri-implantitis with deproteinized bovine bone mineral and enamel matrix derivative.

H ₂ O ₂ [3%] exerts bactericidal effects through oxidation of the cellular components leading to disruption of microbial structures and functions. These properties are enhanced when diode lasers (440– 480 nm) are used as an activating agent. Activation of H ₂ O ₂ with lasers have also been reported to be beneficial against peri-implantitis. Prolonged H ₂ O ₂ use reduces plaque accumulation, gingival inflammation, and enhances post-surgical gingival healing. H ₂ O ₂ irrigation during instrumentation reduces the bacterial load and adjunctive use of 1.7% H ₂ O ₂ gel via prescription trays with SRP causes sustained reduction in PD and GI for up to 6 mo in moderate to advanced periodontitis. While the antimicrobial properties of H ₂ O ₂ are undeniably advantageous, its chemical interaction with titanium poses potential risks of corrosion and weakening of the implant structure, ultimately affecting the longevity of the implant.

Air-polishing (AP) devices, which use a jet of air with low abrasive powder and water, help remove supra and subgingival biofilm, reducing discomfort during periodontal treatment. This method not only improves patient experience but also lowers inflammatory markers in the GCF. Guided-biofilm therapy (GBT) was introduced as an effective protocol for efficient debridement while preserving a tooth structure and surrounding tissues. The commonly used abrasive powders with this technique include, but not limited to, glycine and erythritol. Other powders used include trehalose, sodium bicarbonate, and a combination of erythritol powder with CHX. GBT utilizes airflow with glycine or erythritol powder alongside ultrasonic instrumentation. Erythritol powder is equally effective as glycine in biofilm removal, with enhanced antimicrobial properties, making it a promising alternative. Additionally, erythritol AP is reported to be gentler compared to SRP. Highly abrasive substances like sodium bicarbonate can alter tooth surfaces, while glycine or erythritol effectively remove biofilm, cause less tissue trauma, and are more comfortable for patients. Glycine has immunomodulatory, anti-inflammatory, and cytoprotective effects, which effectively removes bacterial biofilms that cause periodontal inflammation. Subgingival AP powders can impact wound healing, cell viability, and gingival fibroblasts. While cementum loss may be higher than traditional methods, further research is needed. However, studies hitherto show no significant difference in PD, CAL, PI, and REC compared to hand instrumentation or ultrasonic scaling, and further research is needed.

Subgingival airflow therapy with erythritol powder does not significantly enhance clinical and microbiologic outcomes in patients with moderate to severe periodontitis, it may offer some benefits in treating initially deep periodontal pockets. Air polishing with erythritol and CHX appears to be a good substitute, by combining an antimicrobial and antibiofilm agent to more effectively manage biofilm-related infections.

For non-surgical debridement of implant surfaces, erythritol AP has been shown to be an effective and safe modality, and is suitable for implant-supported restorations. Adjunctive use of AP either in combination with other modalities or monotherapy has been shown to result in increased BOP reduction and improved clinical outcomes in peri-implant mucositis or peri-implantitis treatment. AP is considered effective in supra-gingival and sub-gingival biofilm removal, though its effectiveness highly depends on the targeted area accessibility. For management of peri-implant mucositis, non-surgical debridement with glycine powder causes an earlier and sustained return to host-microbial homeostasis compared to ultrasonic instrumentation, and has shown to reduce clinical markers of inflammation for a period of 3 mo. During surgical management of peri-implantitis, when used in combination with ultrasonic instrumentation for debridement of implant surfaces, AP has been shown to minimally alter the surface topography, and aids in bone regeneration. It is also used in combination with cold atmospheric pressure plasma to effectively remove biofilm, with better outcomes on sandblasted/acid-etched surfaces.

Although it is a rare complication, a few cases of subcutaneous emphysema have been reported following the use of AP devices, especially in areas without attached keratinized gingiva. Therefore, clinicians should exercise appropriate precautions when performing these procedures.

Lasers are commonly employed as adjunctive treatment to non-surgical periodontal therapy due to its bactericidal and detoxifying effects. The commonly employed lasers include erbium-doped yttrium aluminium garnet laser (Er:YAG), neodymium-doped yttrium aluminum garnet (Nd:YAG), diode, and CO ₂ lasers amongst others. The advantages of using lasers include, but are not limited to, reduced pain, higher patient compliance and rapid healing. As an adjunct to root debridement, lasers result in reduction of red and orange complex bacterial species. Conventional lasers and low-level laser therapy, when used as adjuncts to SRP, are effective in reducing PD, improving CAL and promoting bone regeneration. Lasers aid in stable coagulation promoting hemostasis and promote bone regeneration.

Lasers are also employed for implant debridement, as they are considered to not cause any implant surface alterations. Non-surgical adjunctive usage of Er:YAG laser has shown to be bactericidal, and results in modest improvements in PD, and clinical inflammation in peri-implantitis. The 2025 American Academy of Periodontology/Academy of Osseointegration consensus reports Er: YAG laser to be the one of the most effective implant decontamination modalities, along with electrolytic cleaning and AP. Lasers (especially Er:YAG) are shown to improve PD, BOP, and cause increased radiographic bone fill during surgical management of peri-implantitis defects. ^,

Nd:YAG is reported to cause melting or cracking of implant surfaces, and hence, is not a preferred option for implant debridement. ^, Other pulsed YAG and CO2 lasers have to be used with caution—the power output of these lasers has to be controlled (below 300 mJ/10 Hz) to prevent detrimental effects on the implant surface. Diode lasers have been reported to be the most effective and least damaging to implant surfaces. ^, Though a rise in temperature above approximately 50F can cause harm to the natural bone vitality, the extent of harm rendered by the thermal effect of lasers on implant surfaces is yet to be elucidated. Various factors, such as optic fiber diameter, pulse duration and energy, wave mode, are reported as factors that influence the thermal effects of lasers. Further long-term controlled studies are needed to confirm the effectiveness of lasers in periodontal and peri implant treatment. Factors, such as laser wavelengths and pulse energy, should be taken into consideration when interpreting results from the existing literature.