October 1, 2012
by C. Fritz,123 L.M. Dakin,1 D.M. Lavoie,1 S.M. Sabo,1 C.P. Hamm,1
While the advent of implant dentistry has provided the option of a fixed prosthetic solution, the responsibility for the maintenance of implant dentistry often rests with the patient and the dental hygienist. Without supportive implant therapy, the possibility of peri-implantitis developing is well established1. However, the development of effective protocols has been limited due to a dearth of randomized control trials and specific protocols with globally available professional instruments and oral hygiene products. This paper describes an effective supportive implant therapy protocol that assists the dentist and dental hygienist in the task of providing life-long support for the patient with single and multiple implants and also a screening mechanism for implant failure (Fig. 1.).
An implant maintenance protocol was developed and has been successfully implemented in a private specialty practice setting maintaining thousands of implants for up to eight years. The protocol is effective with most implant designs, and also importantly, with implants that have not had supportive therapy previously and are referred for screening of peri-implant mucositis and peri-implantitis.
To perform supportive implant therapy, the clinician requires specialized instruments and disposable prophylaxis products (Fig. 2). One of the specialized instruments must be a periodontal probe as probing the implant is necessary to diagnose peri-implant diseases (Fig. 3). A titanium scaler and curette are also necessary to remove accretions and excess cement. The use of a scaler or curette made of plastic or teflon is generally ineffective in supportive implant therapy. The removal of biofilm is also facilitated with a glycine-based air polishing powder (EMS, Switzerland).
THE SUPPORTIVE IMPLANT THERAPY PROTOCOL COMPRISES7 STEPS.
1. Review Medical and Dental Histories.
As with every dental appointment, updating the medical history is mandatory. In particular, changes in smoking status, glycemic control, new medications and trauma can be important in discerning changes to the implant and surrounding structures. Any recent changes in the patient’s occlusion by way of new restorations, parafunction or loss of periodontal support can change the occlusion and subsequent forces on the implant. This can develop in fractures of the implant-supported crown, screw loosening and possibly bone loss around the implant.
2. Ask Two Pertinent Questions: The two essential questions to ask the patient are:
a) Have you noticed any change in the implant area? If the patient reports that they have noticed changes with the implant area, this usually indicates either a restorative complication (i.e., loose crown) or biological complication (peri-implant disease). Neither of these complications resolve on their own. Restorative complications should be evaluated and treated by the restorative dentist or prosthodontist, while biological complications should be referred to the surgeon who placed the implant.
b) How are you caring for the implant? Implants require daily attention and although they are impervious to decay, the periodontal tissues protecting the implant are still susceptible to inflammation. When patients perform daily maintenance of the implant with a powered toothbrush, a cross-over floss technique (Fig. 4) and interdental brushes (Fig. 10), the potential plaque-induced inflammation to peri-implant tissues is minimized.
3. 10 Point Inspection:
1. Plaque and calculus score. The implant is evaluated at 6 sites for the presence or absence of plaque or calculus. Other accretions such as residual cement may be recorded here as well. Ideally, this score is 0. If it is greater than 0, the clinician should provide a strategy of oral hygiene to assist the patient in improving plaque control.
2. Probing depth at 6 sites around the implant. Using a metal probe, the probing depth is measured around the implant using a force of no more than 25 grams (Fig. 3). Relative changes between appointments are more important than absolute measurements. Ideally, the measurements are the same as they were at baseline when the superstructure was placed. An increase of more than 2mm of probing depth between appointments or from baseline is considered a potential biological complication and may suggest peri-implant disease. A referral to the original surgeon for treatment is indicated.
3. Bleeding upon provocation. This is evaluated after probing. Ideally there is no bleeding. If there is bleeding upon provocation, this is a sign of inflammation and a peri-implant mucositis. This is an extremely important finding as it is reversible with appropriate treatment. If this is left untreated, peri-implant mucositis can develop into peri-implantitis quite rapidly. The strategies for treating peri-implantitis are not as effective as they are for peri-implant mucositis so early detection is critical.
4. Suppuration on probing. A positive finding of suppuration indicates a serious biological complication. Systemic or localized antibiotics are generally ineffective in the management of this complication. Prompt referral to the surgeon who placed the implant is necessary. Surgery is likely required to access the implant and thoroughly decontaminate the fixture.
5. Keratinized tissue quality. Ideally, there should be 2mm of attached gingiva around an implant. The lack of attached keratinized tissue predisposes the patient to recession and bone loss around the implant. A lack of keratinized tissue is often noted on the buccal aspects of implants in the mandibular posterior area and the lingual of implants in the mandibular anterior area. A mucogingival graft to add support to the peri-implant tissues is recommended when less than 2mm of attached gingiva is noted.
6. Recession. A healthy implant generally has no recession. If recession is noted around the implant, this is a biological complication that should be evaluated by the surgeon who placed the implant. Implants placed in an immediate fashion tend to develop recession due to the loss of bundle bone more readily than implants placed in a delayed technique. This complication does not usually manifest immediately, but typically takes 3-5 years to develop. Once recession develops around an implant, it is possible to graft the area, however with less predictability than around natural teeth.
7. Mobility. Implants should not have any mobility (Fig. 5). Any mobility with an implant must be investigated. This suggests either a restorative complication (loose abutment or screw) or osseo-separation (loss of implant integration). Both complications must be treated immediately to prevent damage to the internal component of the implant with the former, and bone loss and tissue destruction in the latter.
8. Occlusion. The occlusion of the implant should be kept light enough to allow three layers of shimstock to pass through with the patient in maximum intercuspation as well as in lateral excursions (Fig. 6). Excessive forces can lead to chipping of porcelain and fractures.
9. Contacts. A definitive contact point is ideal. A loose or open contact leads to food impaction which subsequently causes peri-implant inflammation, but more commonly, decay on the natural tooth that is next to the implant.
10. Percussion Sensitivity. There should be no percussion sensitivity with the implant. A positive finding may be indicative of a biological or restorative complication. Peri-implant disease, parafunction and neurological complications can be identified with percussion sensitivity.
4. Radiographic Assessment.
The radiograph taken at the supportive implant therapy appointment is compared to the radiograph taken at the time seating th
e implant-supported crown. This comparison allows the clinician to evaluate changes in crestal bone height as well as other incidental findings such as calculus or cement. The clinician should always examine the natural teeth adjacent to implants as decay can be easily overlooked when focusing on the implant alone. Radiographs of the implant should typically be taken every 24-36 months.
5. Chemical and Mechanical Decontamination of Implant.
The implant is first swabbed with a cotton pledget soaked in fresh 3% hydrogen peroxide (Fig. 7). Hydrogen peroxide is used to detect epithelial and connective tissue degradation around an implant. With peri-implant disease there are metabolites produced that give rise to a vigorous “bubbling effect” from the altered gingival crevicular fluid around diseased implants. When peroxide is locally applied around an implant, and a strong bubbling response is elicited, this may indicate localized deterioration.
Next the implant is mechanically decontaminated supra-gingivally with a prophy cup and zircate paste (Dentsply) or toothpaste. Sub-gingivally a titanium scaler and curette are used (Fig. 8). A glycine-based air polishing powder can also be used to decontaminate subgingivally, as well as threads of exposed implants. Finally, the implant is swabbed with cotton pledget soaked in 0.12% Chlorhexidine (Fig. 9).
6. Home Care Instructions.
A personalized strategy using interdental brushes (Tepe), an electric toothbrush and cross-over floss technique (Figs. 4 and 10) can be quite effective in fostering peri-implant health.
7. Re-assess Recall Frequency.
The frequency is customized to meet the patient’s needs, however 3-4 times per year is generally adequate. When the patient is co-managed between the restorative dentist and surgeon, the patient’s supportive implant therapy is generally performed at the office of the restorative dentist and enhanced through focused supportive implant therapy once every 12-24 months with the surgeon.
By following the strict implant maintenance protocols patients with complex implant supported reconstructions can be successfully maintained over long periods (Figs. 11,12).
Patients who do not adhere to their customized maintenance protocol may be unaware that their complex implant dentistry is at risk of failing, often for similar reasons that led to their original etiology of tooth loss (Fig. 13).
Strict adherence to the implant maintenance protocol prevents peri-implantitis or mucositis for compliant patients (Figs. 11,12). Those deviating from the proposed maintenance program may report similar patient satisfaction from the implant reconstruction but will develop greater bone loss, more bleeding upon provocation and higher plaque scores than the compliant group. This may predispose non-compliant patients to peri-implantitis and late implant failure.OH
C. Fritz,123 L.M. Dakin,1 D.M. Lavoie,1 S.M. Sabo,1 C.P. Hamm1
Reconstructive Periodontics and Implant Surgery Clinic, Fonthill, ON,1 Niagara Health System2 & Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada.3
Oral Health welcomes this original article.
1. Lang NP, Berglundh T; Working Group 4 of Seventh European Workshop on Periodontology. J Clin Periodontol. Periimplant diseases: where are we now?—Consensus of the Seventh European Workshop on Periodontology. 2011 Mar;38 Suppl 11:178-81.