Implant dentistry has resulted in the dental hygienist playing a critical role in the long-term survival of implanted teeth. Supportive care aids the patient in maintaining the beauty of the prosthesis.
Francis G. Serio, DMD, MS
Implantology has been a revolutionary force in dentistry during the past 30 years. The root-form endosseous implant enables many patients - who previously have been relegated to ill-fitting removable prostheses - to have prostheses offering greater stability and security. Both implant-supported dentures and implant-supported fixed prostheses improves patients` masticatory ability, confidence, and quality of life.
Implants also change the way the dentist approaches treatment planning. Before implants became relatively predictable and routine, many periodontally involved teeth were maintained to either support a bridge or removable partial denture, or to keep a dentition intact and the patient from needing a prosthesis. Keeping such teeth healthy provided a significant challenge to both patient and hygienist alike. Many of these questionable teeth are now removed if there appears to be enough remaining alveolar bone for the placement of an implant.
Despite the enthusiasm generated by implant dentistry, it is important to remember that the majority of implant patients are dental failures. It is critical to identify why these patients lost their natural teeth and help them understand the importance of proper maintenance of their new fixtures and restorations. Inadequate patient education, both prior to and after implant placement, will lead to eventual failure of the fixtures. Many plaque microorganisms associated with periodontitis around natural teeth are also implicated in peri-implant infections.
The dental hygienist`s role is paramount in implant survival for the patient. While many implants are placed in surgical specialty practices, it often falls upon the restoring practice for long-term patient maintenance. In many practices, the hygienist has the primary role in maintenance and providing supportive therapy. This is made easier with restorations which have been designed with sufficient embrasures to accommodate oral hygiene procedures.
The purpose of this article is to outline many of the supportive care, hygiene, and prevention products available to keep implant supporting tissues healthy.
Biomechanics of implants
While a multitude of implants are available, most are variations of two basic design patterns. The implant fixtures are made of relatively soft commercially-pure titanium or a harder titanium alloy. The implants may be of either a threaded screw or press-fit design. Press-fit implants have had their surface roughened by plasma sprayed with molten titanium. Some implants are coated with hydroxyapatite to create a more biocompatible surface with bone.
The coronal aspect of all implants has a highly polished collar, which may be from 1 mm to 4 mm wide. This polished collar can be kept relatively plaque-free by using soft brushes and instruments. Many of the instruments used routinely for the maintenance of natural teeth will scratch the polished collar, thereby increasing plaque retention in the area. Studies also have demonstrated that ultrasonic devices can cause significant damage to the implant surface and even remove the hydroxyapatite coatings from the implant surface.
Histologically, the attachment of the gingival tissues to the neck of the implant is distinct from the attachment to natural teeth. While the tooth has both junctional epithelium and the supracrestal connective tissue fibers attached to the tooth coronal to the bone, the implant has only a junctional epithelium attachment to protect the bone. As such, this attachment is more fragile and susceptible to damage by trauma. The connective tissue fibers found adjacent to the junctional epithelium with implants run parallel to the fixture and do not insert into the implant surface.
Probing implants must be done with care. Plastic probes should be used since stainless-steel probes can mar the implant surface.
A gentle probing force must be used so that the tip of the probe does not penetrate the junctional epithelium and connective tissue all the way to the bone. In healthy tissue, the probe will stop at the coronal level of the connective tissue. In the presence of inflammation, the probe tip will penetrate close to the bone. Probing is critical to judge the health of an implant, because as the probing depth increases, the patient`s effectiveness in daily oral hygiene diminishes.
The implant maintenance appointment
The maintenance appointment for implant patients is in many ways similar to that of a patient with only natural teeth. Some notable exceptions include:
- Only plastic or titanium instruments may be used on the implant surface. Standard stainless-steel scalers and curettes will scratch the implant surface. Even titanium-tipped scalers will create subtle scratches on a highly polished implant surface.
- Ultrasonic instrumentation is also damaging to the implant surface, but the use of a sonic scaler with plastic inserts (Quixonic, Dentsply/Midwest) is suitable.
Protocols for the assessment and supportive treatment for implant patients have been developed. Steps referred to in Periodontology for the Dental Hygienist (W.B. Saunders) include:
_ Remove superstructure - If the superstructure is screw- retained, check for tightness. The cause of superstructure mobility must be differentiated between loose screws and a failing implant. Removal of a screw-retained superstructure will facilitate cleaning the implant fixtures. There is a trend toward cementing restorations to decrease the excessive immediate loading of implants from slightly misaligned screw-retained superstructures.
_ Evaluate tissue for tone, color, consistency, size, and texture - This is most easily done after the restoration has been removed, if possible. Erythema, edema, and suppuration are the usual signs of inflammation.
_ Check for mobility - This may not be possible with splinted implants. Be sure to differentiate mobility of the healing collar or abutment from mobility of the implant itself. A loose implant is a failed implant which must be removed.
_ Probe implant sulcus depth - As mentioned previously, use only a plastic probe, six measurements per implant. Increasing probing depths will make hygiene procedures more difficult and may lead to peri-implantitis.
_ Evaluate plaque for quantity and location - Modification of the patient`s home-care regimen may be in order. Creative approaches to designing a specific regimen is sometimes necessary.
_ Evaluate calculus for quantity and location - All calculus must be completely removed to minimize the rapid formation of new deposits on residual calculus. Calculus is relatively easy to remove from the highly polished implant collar. Calculus may be significantly more difficult to remove from a roughened collar or the implant body itself.
_ Radiograph implant area - This interval is determined by the dentist. Often, there is radiographic evidence of bone loss to the first thread within the first year. The reasons for this are controversial. Many researchers feel that this is normal while others think that this early bone loss may be a result of occlusal overload of the implant. Implants which are ailing may show vertical defects similar to those seen on teeth. A radiolucency down the side of an implant or around the apex signifies major problems with the fixture.
_ Record assessments - This step is the reference point from which future conditions are evaluated.
Hygiene treatment procedures for implant treatment start out by emphasizing home care instructions, focusing particularly on missed plaque. Have the patient demonstrate these new procedures. Behavioral modification may also be necessary if the patient is reverting to the poor habits that caused teeth loss in the first place.
Various aids may assist the patient with better oral hygiene. Powered toothbrushes such as the Sonicare Plus sonic toothbrush (Optiva), Rota-Dent (Pro-Dentec), and Braun Oral-B brushes may be more effective than manual brushes in working around implants. The Rota-Dent has a tapered brush which can fit under many fixed restorations. Although caution must be used in interpreting study results, recent research suggests that the Sonicare Plus brush may be superior to other powered brushes under certain conditions.
Superfloss (Oral-B), Proxi-Floss (Advanced Implant Technologies), and Postcare (J.O. Butler) are designed to provide effective yet safe plaque removal from implant surfaces through flossing techniques. Interproximal brushes with nylon coated wires, the Soft Foam (Oral-B) insert, or brushes which do not have a wire core (Advanced Implant Technologies) can also be used.
Chlorhexidine gluconate may be used adjunctively to control plaque and gingival inflammation. Recent evidence suggests that subgingival irrigation with a Pik Pocket (Teledyne Water Pik) using 0.06 percent chlorhexidine gluconate is more effective at reducing gingival inflammation than rinsing with 0.12 percent chlorhexidine gluconate once daily.
Other treatment considerations include:
- Remove supra and subgingival plaque on implant - Use an implant-friendly plastic curette such as those from Advanced Implant Technologies, Hu-Friedy, or Sterngold-ImplaMed. A sonic scaler with a rubber tip (Quixonic, Dentsply/Midwest) may also be used. Never use a powered scaler with a metal insert on an implant surface.
- Remove supragingival plaque and stain - Use a rubber cup and fine paste, tin oxide, or toothpaste. Be sure not to heat the implant by using too much force or too high a speed with the rubber cup.
- Clean superstructure - This may be done with ultrasonic scalers, ultrasonic cleaners, or air-power polishers.
- Clean any remaining natural teeth.
- Caries and sensitivity control - Follow judicious use of fluorides and desensitizing agents.
- Establish recall interval - These patients may need more frequent appointments to help them maintain their health and protect their substantial investment. For some patients, a three month interval may be too long.
Proper maintenance is the key to implant survival. While the principles are the same as with natural teeth, care must be taken to use instruments which are both effective and safe for the implant surface. The dental hygienist plays the crucial role in the survival of implants in any practice.
Francis G. Serio, DMD, MS, is professor and chairman of the department of periodontics at the University of Mississippi School of Dentistry. Questions about this article can be directed to him at: 2500 North State St., Jackson, MS 39216-4505; (601) 984-6115; [email protected].
- Meffert RM. Maintenance of dental implants. In Misch CE. Contemporary Implant Dentistry. St. Louis, Mosby-Year Book, 1993, pp.735-762.
- Donley TG, Gillette WB. Titanium endosseous implant- soft tissue interface: A literature review. J Periodontol 1991;62:153-160.
- Lang NP, Wetzel A, Stich H, Caffesse RG. Histologic probe penetration in healthy and inflamed peri-implant tissues. Clin Oral Impl Res 1994;5:191-201.
- Perry DA, Beemsterboer PL, Taggart EJ. Periodontology for the Dental Hygienist. Philadelphia, W.B. Saunders, 1996, p. 258-275.
- Wilson TG Jr. A typical maintenance visit for patients with dental implants. Periodontol 2000 1996;12:29.
- Yankell SL, Emling RC, Shi X. Interproximal access efficacy of Sonicare Plus and Braun Oral-B Ultra compared to a manual toothbrush. J Clin Dent 1997;8:26-29.
- Robinson PJ, Maddalozzo D, Breslin S. A six-month clinical comparison of the efficacy of the Sonicare and the Braun Oral-B electric toothbrushes on improving periodontal health in adult periodontitis patients. J Clin Dent 1997;8:4-9.
- Felo A, Othman S, Ciancio SG, Lauciello FR, Ho A. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent 1997;10:107-110.
Many products help ensure the longevity of dental implants. Pictured above are (clockwise from upper left) Proxi-Floss interdental aid; the PDT plastic periodontal probe; the Pik Pocket irrigation tip; the Implant Prophy+ Gracey 11/12 curette on top and the Implacare handle with assorted tips on the bottom; Rota-Dent (left to right), Braun Oral B, and Sonicare powered toothbrushes; and Butler Proxabrush (left to right), Proxi-Tip, and Oral B Soft Foam insert interproximal brushes.
Products for implant maintenance
Numerous instruments for implant maintenance are available from several manufacturers and distributors. The following list is meant as a guide - not as an all-inclusive list of products for implant-maintenance procedures.
> Implant-Prophy+ Plastic Dental Instrument System - The system has several plastic polymer curettes with the Gracey design (5/6, 11/12, 13/14, and the Columbia 13/14). The instruments are designed to be resharpened with a special sharpening stone and will withstand at least 75 autoclave cycles and still be effective.
> Proxi-Tip Interproximal Brush and Stimulator - This brush has plastic bristles and a plastic core so that there is no metal wire near an implant surface.
> Proxi-Floss Disposable Elastomeric Cleaning Appliance - This floss has a textured surface designed to carry medicaments to the interproximal implant surface.
Advanced Implant Technologies Inc., 8920 Wilshire Blvd., Suite 316, Beverly Hills, CA 90211; (800) 876-4620.
> Periogard - 0.12% chlorhexidine gluconate.
Colgate Oral Pharmaceuticals Inc., Colgate-Palmolive Co., One Colgate Way, Canton, MA 02021; (800) 2-COLGATE; http://www.colgate.com.
> Quixonic Sonic Scaler with SofTip disposable prophy tips - The soft plastic tips may be used against an implant without danger of marring the surface.
Dentsply/Midwest, 901 West Oakton St., Des Plaines, IL 60018; (800) 800-2888; fax: (708) 640-4891.
> Implacare Oral Implant Maintenance Instruments - This system is designed with disposable plastic curette heads in several designs (4R/4L, 204S, H6/7) for use with a reusable autoclavable handle. The Plasteel tips may leave a smoother surface on titanium than plastic, glass, or graphite tips.
Hu-Friedy Mfg. Co., 3232 N. Rockwell St., Chicago, IL 60618-5982; (800)HU-FRIEDY.
> G-U-M Proxabrush Interdental System - handle and tips; must use nylon-coated wire brushes.
> Postcare Flossing Aid for Dental Implants - This is similar to very thick floss.
J.O. Butler Co., Chicago, IL 60630; (800) JBUTLER; http://www.jbutler.com.
> Sonicare Plus - Sonic toothbrush.
Optiva Corp., 13222 SE 30th St., Bellevue, WA 98005; (800) 676-7664.
> Braun Oral-B Plaque Removers.
> Braun Oral-B Interclean Interdental Plaque Remover - This is a mechanical oscillating interproximal cleaner. This is effective for patients who cannot manipulate floss.
> Oral-B Floss.
> Oral-B Super Floss.
> Oral-B Ultra Floss.
> Oral-B Perioflex Subgingival Irrigator.
> Oral-B Interdental Brush System (Soft Foam refills) - These foam cylinders may be used alone or in conjunction with toothpaste or an antimicrobial rinse. Nylon-coated wire interproximal brushes are also available.
Oral-B, 600 Clipper Drive, Belmont, CA 94002; (800) 44-ORALB; http://www.oralb.com.
> Peridex - 0.12 percent chlohexidine gluconate.
Procter & Gamble, Cincinnati, Ohio.
> Rota-Dent toothbrush
> Rota-Point Interdental Cleaners - These are plastic interdental stimulators.
> Pro-Select3 - 0.12% chlohexidine gluconate.
Pro-Dentec, P.O. Box 3889, Batesville, AR 72503; (800) 228-5595; http://ww.prodentec.com.
> Teflon-coated, rounded irrigator syiringe tips for use with irrigation syringes or bottles.
SDI Laboratories, Inc., 10350 Dearlove Road #B, Glenview, IL 60025; (800) 227-8507.
> Implant-Prophy+ Kit - (see Advanced Implant Technologies Inc.).
Sterngold ImplaMed, 23 Frank Mossberg Drive, P.O. Box 2967, Attleboro, MA 02703-0967; (800) 243-9942.
> Pik Pocket Subgingival Delivery Tip for the Water Pik Oral Irrigator.
Teledyne Water Pik, 1730 E. Prospect Road, Fort Collins, CO 80553-0001.