Background: Peri-implantitis, a biofilm-induced inflammatory condition, poses a significant threat to implant survival. Nonsurgical interventions such as air-abrasive polishing and conventional periodontal therapies are frequently employed, yet their relative effectiveness remains debated. Aim: This systematic review aimed to evaluate the relative performance and clinical efficacy of air-abrasive polishing compared with other nonsurgical approaches in the management of peri-implantitis. Methods: A systematic literature search covering PubMed, Scopus, OVID, Web of Science, Embase, and EBSCOhost was conducted (September 2024 with an update in May 2025), adhering to PRISMA standards. Only randomized controlled trials (RCTs) directly assessing air-abrasive polishing against alternative nonsurgical therapies were included. The primary outcomes assessed included probing depth, bleeding on probing, changes in clinical attachment, and inflammation. Study quality was evaluated using the Cochrane RoB 2 tool. Results: Four RCTs (2011–2023; 172 participants) fulfilled the eligibility criteria. A 2011 RCT reported short-term microbiological reductions with both Er:YAG laser and air-abrasive polishing, although neither approach sustained clinical benefit over six months. A 2022 RCT found erythritol air polishing comparable to ultrasonic scaling; however, neither modality achieved disease resolution, and most cases required subsequent surgery and other study demonstrated that supportive peri-implant care (SPIC), combining glycine air polishing with ultrasonic debridement, maintained reduced probing depths for one year post-surgery. A 2023 RCT observed no added benefit from adjunctive erythritol polishing and noted increased discomfort, particularly among female patients. Collectively, findings suggest nonsurgical interventions provide only limited improvements without eliminating peri-implantitis. Conclusions: Air-abrasive polishing may have value as an adjunctive or maintenance strategy, particularly within supportive care, but is insufficient as a standalone therapy for established peri-implantitis. Further well-designed trials with standardized protocols, extended follow-ups, and patient-centered outcome measures are warranted.
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