October 8, 2019
by Peter C. Fritz; Donna M. Lavoie; Roxanne More; Linda M. Dakin; Angie Nahli; Amanda B. Longo
It has been eight years since we published our Supportive Periodontal Implant Maintenance Protocol1 which has been shared and implemented in dental practices and hygiene colleges across the globe. With the exciting new periodontal and peri-implant classifications published simultaneously by the American Academy of Periodontology and European Federation of Periodontology, we felt it was necessary to revisit our implant maintenance protocol to better reflect the new information and technologies available today. This article is focused on the best evidence to prevent peri-implant mucositis and peri-implantitis using a systematic approach which is personalized for the patient. This critical update has eliminated several steps from our former algorithm and replaced them with innovative approaches generated from new concepts of peri-implant health.
It is impossible to separate the health of the implant from the periodontal health of the natural dentition and that is why a more comprehensive approach is now suggested. Implantology is a collaborative art involving many stakeholders including the patient, surgeon, restorative dentist, dental hygienist, denturist, lab technician and implant company. Everyone is completely aligned in that they do not want any complications with the final result. However, many complications can occur with implants and many of these do not emerge until the implant has been in function for three to eight years which should be regarded as the “danger zone.” Fortunately, many of the complications are preventable by following proper implant maintenance guidelines and working cooperatively as a team in the best interest of the patient.
Implants should be regarded as high maintenance dental devices and it is clearly dangerous to consider implantology in the absence of periodontology. Roccuzzo and colleagues compared implant health in patients with a healthy periodontium to those with moderate and severe periodontal disease.2 Less than every tenth implant in the periodontally healthy group but every third implant in the moderate group and every second implant in the severe (periodontal) group had probing depths 6 mm or greater at implant sites.2 Regular periodontal maintenance was a predictor for implant health despite a standardized approach for implant maintenance.
In a systemic review of epidemiological literature, the reported mean prevalence of peri-implant mucositis is 43% and peri-implantitis is 22% of implant patients.3 Statistically, a peri-implantitis is found at every tenth implant and in every fifth implant patient after a five to 10-year period. Because peri-implantitis is most often associated with a bacterial biofilm induced infection, a lifetime of biofilm management is required to ensure implant survival. Dental implants are different from any other implanted devices in humans because once placed, they are never sterile. Only 30 to 120 minutes after implant placement, the peri-implant sulcus takes on the nearly identical microbiological profile as the neighbouring teeth underscoring the inextricable links between periodontal and implant health.4
A useful analogy is to compare a bacterial biofilm to a large metropolitan community. There is a power grid, waste channels, food stores, communication lines, security services and delivery pipelines. It’s a complex, diverse, three-dimensional, resilient community or consortium trying to grow and thrive without being disrupted by external influences. Biofilms are found everywhere including on rocks in streams, airline tray tables, aquarium glass, on the surface of plants and on the hull of canoes. Given that on a microscopic level, implants are pitted like the surface of the moon, it is no wonder biofilms develop so readily around implants and are capable of causing inflammation and bone loss to the susceptible surrounding tissues.
The supportive periodontal therapy “recall hour” consists of 5:
The Fonthill Implant Care Protocol adapts the “recall hour” into six stages outlined in Figure 1. The six stages of Implant Care are to assess, disclose, motivate and empower, instrument, check and document, and recall. These six stages are adapted from the Guided Biofilm Therapy protocol for dental biofilm management as proposed by EMS (Nyon, Switzerland). Our evolving supportive implant maintenance protocol continues to successfully maintain more than 8000 implants in a private specialty practice (Fonthill, ON, Canada). The protocol is useful for all implant designs and for implants not having had previous implant care. This protocol allows the early identification of peri-implant mucositis and peri-implantitis and has recently been tailored to reflect the disruptions in biofilm management strategies.
The Fonthill Implant Care Protocol.
The following instruments and devices are required to deliver contemporary implant care.
The Fonthill Implant Care Protocol
The assessment stage requires a review of the patient’s full medical and dental history as well as clinical and radiographic examination.
A review of the patient’s medical history should always be undertaken at every dental visit. Changes in the patient’s glycemic control, smoking status, medications contributing to hypo-salivation and immune health are of particular relevance to implant health.
The negative and serious effect of cigarette smoking is well established on implant health. The effect of smoking is cumulative and impairs the natural healing process. For example, the periodontal healing capacity of a 50-year old smoker is the same as that of an 86-year-old non-smoker6,7 and tissues can take over a decade to recover after quitting.
The effect of cannabis and vaping is presently unclear on the health of dental implants, however, given the toxicity of one joint being greater than or equal to two and a half to five cigarettes due to its higher level of combustion8, we would speculate cannabis may be as deleterious to implant health as cigarette smoke. With the recent legalization of marijuana, Canadian research will likely be on the cutting edge as its consumption and the link to health and disease is a research question being asked by many in the dental and medical fields, alike. The effect of vaping is less clear at this time however is likely to have the same if not greater deleterious effects on implant health.
A comprehensive dental history is also imperative to collect in the assessment stage. Poor oral hygiene and compliance, a history of periodontitis and cigarette smoking were found to be pivotal risk indicators for development of implant complications and are summarized in Figure 2.9,10
Odds ratio of risk indicators for the development of peri-implant disease.
The 10-point clinical examination to be used in the assessment of peri-implant health and disease is presented below and has been summarized in Table 1.
Ten-point inspection for clinical examination in the assessment of peri-implant health and disease.
1. Probing Depth: In addition to probing the entire mouth, six sites around the dental implant should be probed with a metal probe with a pressure no greater than 22 grams (Fig. 3). This probing should be compared to the probing measurements at the time the superstructure was delivered. Relative changes between appointments are more important than absolute changes and ideally there should be no variation from the measurements taken at baseline.
Probing with a metal periodontal probe.
Unlike around natural teeth, the probing depth around implants may be more than 5mm and still be healthy due to the placement depth of the implant as well as the physiology of the mucosal seal around the implant. As a general rule, if the probing depth does not increase over baseline measurements, the peri-implant tissues can be considered healthy. An increase of 2 mm or more in probing depth is considered a potential biological complication and may suggest progression from peri-implant health toward disease. A referral to the surgeon who placed the implant is indicated as peri-implant mucositis or peri-implantitis management may be necessary. A systemic antibiotic or sub-gingival irrigation will most likely be ineffective in the treatment of a peri-implantitis.
2. Bleeding Upon Gentle Provocation: Immediately after probing, the assessment for profuse bleeding, a bleeding point or line is assessed. Ideally, there is no bleeding suggesting peri-implant health. Any bleeding is a sign of inflammation and is a symptom of peri-implant mucositis and possibly peri-implantitis. With the Fonthill Implant Care Protocol peri-implant mucositis is often reversible. However, if left untreated, mucositis may progress to a peri-implantitis may rapidly and non-linearly. Given the challenges of treating peri-implantitis, early detection of mucositis is critical. A summary of the updates to the Global Classification System for Peri-Implant Health, Peri-Implant Mucositis, and Peri-Implantitis have been published in this edition of this journal.
3. Suppuration: A positive finding of suppuration indicates a serious biological complication. This finding triggers the prompt referral of the patient to the surgeon who placed the implant. Systemic or localized antibiotics are not effective and surgery will likely be required to stabilize the periodontal tissues, decontaminate the implant and repair the bone loss. At the risk of inducing an air emphysema in the fragile subgingival tissues around an implant, subgingival air-polishing decontamination should not be attempted.
4. A. Keratinized Tissue: It is advantageous to have a thick collar of keratinized tissue supporting the implant. This provides resistance to abrasion as well as rigidity to the peri-implant sulcus. A lack of attached keratinized tissue predisposes the patient to recession and bone loss around the implant and is often noted on the buccal aspects of implants in the mandibular posterior and the lingual of implants in the mandibular anterior. Where there is less than 2 mm of attached gingiva around an implant, a mucogingival graft to add support to the peri-implant tissues is recommended.
B. Recession: A healthy implant generally experiences no recession. If more than 2mm of recession is noted around the implant, this should be flagged as a biological complication and should be evaluated by the surgeon who placed the implant. Immediate implantation is associated with more recession due to the loss of bundle bone when compared to implants placed using a delayed technique. Recession does not usually manifest immediately, but typically takes several years to develop. Once recession develops around an implant, it is possible to graft the area. However, outcomes of a graft around an implant is less predictable than that around natural teeth. Depending on the thickness of the tissue supporting the implant, often the recession will arrest once past the gap of the implant/abutment or crown/abutment interface.
5. Occlusion: Changes in the patient’s occlusion can increase forces on the implant predisposing it to damage of the crown (chipping, cracks), screw loosening and possibly bone loss around the implant. These changes include new restorations, loss of periodontal support, parafunction or orthodontic therapy. The occlusion of the implant should be kept light enough to allow two layers of shimstock to pass through the occluding teeth with the patient in maximum intercuspation and in lateral excursions (Fig. 4).
Use of shimstock to assess occlusions.
6. Interproximal Contacts: A definitive, wide contact point is ideal. A loose or open contact leads to food impaction which subsequently can cause peri-implant inflammation, but more commonly, leads to decay on the natural tooth adjacent to the implant.
7. Embrasure Space Amenable for Oral Hygiene: There should be adequate space between implants, between implants and teeth, under bridges and around bars to allow for effective personal mechanical plaque control. Too often a fixed prosthesis is designed that restricts the patient from using an interproximal brush or floss to mechanically disturb the biofilm on all surfaces. Adequate embrasure space is a non-negotiable parameter for long-term peri-implant health.
8. Mobility: Mobility of an implant is assessed differently from natural teeth. Perhaps a better term is a rotation. Rather than moving the crown in a buccal-lingual direction with two instruments, the implant requires a more personal touch. This is best assessed using the finger and thumb in a rotational manner and assessing for the slightest amount of rotation.Implants should not have any rotation or buccal-lingual 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 to prevent damage to the internal component of the implant with the former, and bone loss and tissue destruction in the latter. The use of non-original equipment manufacturer components is often the source of implant mobility.
A test of mobility/rotation of the implant.
9. Condition of Prosthesis: The condition of the crown, superstructure, or over denture and locators must be evaluated for cracks, chips, retention and the ability for the patient to clean around it (prosthesis design).
10. Plaque/Biofilm: Updated from our previously published version of the implant care protocol, the evaluation of plaque/biofilm distribution on the crown, implant surface, adjacent teeth, and peri-implant tissues is now the final step in the clinical assessment. Disclosing the field with a plaque disclosing solution is suggested for this final step. Once disclosed, an intra-oral photograph should be taken of the area to document the plaque distribution and to serve as a launching point for a meaningful oral hygiene discussion. For anterior teeth or where aesthetics are of a concern, intra-oral photographs are recommended to document the condition of the tissues and implant prior to disclosing plaque.
It is essential to have a radiograph taken at the time the implant crown is delivered. This serves as a useful comparison and 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 not be taken to celebrate an anniversary, but rather according to the following protocol:
Updated from the previous version of the Implant Care Protocol, plaque score has been eliminated from the assessment in favour of making the biofilm visible through a disclosing agent (Fig. 6). Using a disclosing agent serves three purposes, 1) records the plaque distribution (marginal tissues vs. enamel surface), 2) allows an interactive discussion with the patient regarding biofilm mitigation strategies, and 3) allows for guided biofilm management by the clinician.
Use of disclosing agent to visualize and assess plaque and biofilm accumulation. A powerful tool for patient motivation and empowerment.
Using a disclosing solution breaks down many barriers to communication with the patient. Many patients overestimate the effectiveness of their oral hygiene regimen and despite investing in expensive brushes, patients often require some coaching on how to improve. Disclosing solutions quickly demonstrate to the patient that technique is very important in effective home care. Patients can’t ignore the personal, factual, indisputable evidence revealed through disclosing. It allows the dental professional to engage in a discussion of precision oral hygiene instruction tailored to the patient.
Fundamentally, dental professionals are taught to remove deposits (calculus, plaque, stain) from teeth and leave the cleanest surface behind. Biofilm plays a bigger role than calculus in the disease process, but it is invisible to the naked eye. Clinicians are drawn to stain and calculus because it is easy to identify. When we disclose biofilm, we can suddenly see the stain on the patient’s teeth that may unknowingly be left behind otherwise.
Framing the conversation about disclosing is important in maximizing the benefit of good home and professional oral hygiene. Patients need to be informed that the disclosing is for their benefit, and not to embarrass them. A useful phrase to highlight this point is, “We are using a dye to help see the bacteria on your teeth so they can be thoroughly removed.”
Using a microbrush, disclosing the biofilm around the implant gives the clinician a guide to focus therapy on and facilitates the guided disruption of the biofilm. A photo of the disclosed area provides a useful record of the level of plaque control without having to assign an arbitrarily calculated number (i.e., plaque score). The use of an OptraGate is a useful retraction method to avoid staining the patient’s lips with the disclosing agent.
3. Motivate and Empower
Two essential questions to ask the patient at each supportive periodontal therapy appointment:
A. Have you noticed any change in the implant area?
If the patient has noticed changes, this usually indicates a restorative (loose crown or food impaction) or biological complication (peri-implant disease). Intervention is required as these complications will not resolve spontaneously.
B. How are you caring for the implant?
Implants are high maintenance devices requiring daily attention. Although they cannot develop decay, they still develop a significant biofilm and this can lead to clinically significant inflammation.
When asking questions of the patient, it is important to listen not with the intent to reply, but to understand. The goal is to develop a personalized plan for the patient which includes sustainable patient administered mechanical plaque control. Raising awareness that the implant is different from natural teeth is also important. This should include using a powered toothbrush and interdental brushes or a cross-over floss technique (Fig. 7). When using floss on rough implant surfaces or restorations, floss remnants may be left behind which may in turn lead to plaque-related peri-implant inflammation. As such, in cases of exposed rough dental implant surfaces interproximal brushes (i.e., Tepe, Gum, etc.) or soft picks may be a better mechanical plaque control strategy.
Demonstration of the cross-over floss technique.
Given the ineffectiveness of any subgingival irrigation on disturbing the biofilm, a new strategy is required for implant maintenance. We have eliminated the pre-instrumentation peroxide swabbing of the tissues as well as the chlorhexidine application post-instrumentation from the updated version of the implant care protocol.
Powder and air jet devices should be used to remove sub- and supra-gingival biofilm and staining around implants (Fig. 8). They are gentle on soft tissues, allow for shorter treatment times and may cause less discomfort for the patient. The most commonly used powders are sodium bicarbonate, glycine and erythritol (Table 2). The powder type is very important. Sodium bicarbonate can be used to remove stains on enamel surfaces, but it should not be used on soft tissues or on implant surfaces. Glycine is recommended for supra-gingival polishing around teeth and implants. Erythritol powder can be used on both sub- and sub-gingival surfaces around implants and is therefore the recommended powder to be used in air polishing devices.
Supra-gingival guided biofilm removal with the use of air polishing.
A comparison of available air polishing powders and their uses.
In periodontal probing depths of 1-4 mm, glycine-powder air polishing using a standard air polishing nozzle is more effective at removing sub-gingival biofilm than manual or ultrasonic instruments.11 At probing depths of 5-9 mm, using a sub-gingival nozzle, erythritol powder air polishing is more effective at removing sub-gingival biofilm than manual or ultrasonic instrumentation11 (Fig. 9). For sub-gingival sites, a sub-gingival nozzle is required to deliver the water-directed powder spray. This can be achieved in 5 second bursts in pockets greater than 5 mm.
Sub-gingival biofilm removal with the use of air polishing.Photos courtesy of Dr. Magda Mensi
There are some contraindications to air polishing and requirements before instrumenting with a supra- or sub-gingival air polisher. Patients with a known allergy to erythritol or chlorhexidine are not candidates for sub-gingival air polishing.
Given air polishing produces aerosols, the use of a high-volume suction is required as are the universal precautions normally used for all patients. A pre-procedural rinse, such as 0.12% chlorhexidine may reduce the bacterial contamination of aerosols and is recommended. With patients who have respiratory problems such as chronic obstructive lung disease, or any condition that interferes with breathing or swallowing, air polishing should be avoided. All patients should wear protective eyewear and there has been some debate about potential damage to contact lenses with air polishing.
5. Check and Document
Once the air-polishing is complete, an explorer is gently used to determine if there are any foreign bodies in the sulcus. Calculus can be removed with a titanium curette or scaler. Because a biofilm can live under the calculus, a second round of air polishing is recommended if an accretion has been liberated during this step. Other foreign bodies may include residual cement, bone chips or tooth fragments and careful evaluation of the radiograph may help the clinician identify these potential liabilities. Detailed documentation, including intra-oral photos and radiographs (if necessary) are an essential part of this Implant Care Protocol.
The frequency of the implant care protocol is customized to meet the individual patient’s needs. A history of periodontal disease would support a three-month recall interval. With no history of periodontal disease, the implant care protocol should be performed on a 6-month interval.
Regular, thorough periodontal maintenance is required for all implant patients, especially those with a history of periodontitis. Frequency does not take the place of thoroughness. Early identification of implant problems and evidence-based interventions can prevent more serious complications. Co-operation by the entire dental team is required for the successful outcome for the patient. The implant care responsibility is a critical component of informed consent prior to implant surgery and should be discussed with the patient. This responsibility needs to be consensually assigned and not simply delegated or assumed by the surgeon.
Peri-implantitis is a silent disease and patients are generally unaware of a problem unless a dental professional alert them to the situation. This article is not meant to provide guidelines on how to treat peri-implantitis due to poor surgical or technical execution. However, along with proper periodontal maintenance of natural teeth, it does contribute to the foundation of oral health. Strict adherence to the implant care protocol can prevent peri-implantitis and mucositis and serves to ensure that the implant is the successful long-term solution all stakeholders plan for it to be.
Oral Health welcomes this original article.
Acknowledgements: The authors would like to acknowledge the work of Dr. Magda Mensi and her permissions to use her clinical photos to support this work (Fig. 9).
About The Author
Dr. Fritz, BSc, DDS, FRCD(C), PhD (Perio), MBA is a full-time periodontist in Fonthill, ON and is on a mission to redefine the way people think about periodontal and implant wellness. He leads an extraordinary, collaborative, empowered team of clinicians, makers, scientists and artists who are all working together to innovate the dental specialty of periodontics and redefine the patient experience.
Donna M. Lavoie, RDH is a full-time dental hygienist in the practice of Dr. Peter C. Fritz. Donna has been involved in clinical practice, research projects and peer mentoring of dental hygienists.
Roxanne More, RDH is a full time registered dental hygienist in the practice of Dr. Peter C. Fritz. She has nearly 30 years of clinical experience and has an endless passion for learning.
Linda M. Dakin, RDH is passionate about educating dental hygienists. She graduated from Niagara College in 1987 and obtained her teaching adults certification in 2001. She is a full-time clinical hygienist in a periodontal office in Fonthill, Ontario. She is also a part time clinical and periodontal educator at a private dental hygiene college. Linda has lectured internationally on periodontal therapy, implant therapy, and research methodology.
Angie Nahli, RDH is a registered dental hygienist honing her clinical skills full-time at a periodontal practice in Fonthill, ON. Angie has found her passion in the reinvention of today’s patient experience through the integration of technology. In the last year, Angie designed and launched an application available on the App Store and Google Play, used chair-side by dental professionals worldwide.
Dr. Amanda B. Longo, BSc, MSc, PhD is the Chief Innovation Officer and Director of Strategy of a private periodontal surgery clinic in Fonthill, ON. She is internationally recognized through her influence in research, innovation and knowledge mobilization. Amanda’s key strength is as a catalyst for optimizing team performance and implementing innovative initiatives for the benefit of the individual, the team, and the patient of tomorrow.
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