Implant Maintenance
Morag Powell Dip Dh Dip DT RCS (Edin)
Learning objectives
Upon completion of reading this article, the dental professional should be able
to:
 Describe the differences between peri-implant mucositis and periimplantitis
 Describe how to effectively screen dental implants for peri-implant
diseases
 Have a knowledge of oral hygiene aids that are available to use for the
prevention of inflammation around implants.
Peri- implant disease
As dental implants become more commonplace within every day practice, the
rise of dental implants with inflammation present around them is very evident.
Peri-implant disease is a collective term for inflammatory processes that occur
around tissues that surround the implant.1 This inflammation around dental
implants can be placed into two categories: peri-implant mucositis and periimplantitis. The term peri-implant mucositis is used to describe reversible
inflammation of the soft tissues surrounding implants. Peri-implantitis is the
term used to describe an inflammatory condition that involves both the soft
tissues and the surrounding bone of the implant.2
Implants can fail very early on after placement as a result of the implant failing to
integrate with the bone. These types of failures are known as early implant
losses. Implants can also fail during function – this is when an implant has been
placed, restored and has been used in function in the patient’s mouth for a length
of time. Implants that fail during function can be the result of biologic processes
characterized by clinical signs (eg, implant mobility) that emerge only when an
advanced and possibly irreversible state of the disease has been reached.2 It is
therefore of vital importance that implants are monitored for signs of disease as
routine when presenting in the hygienists/dentists surgery.
The hygienist’s role with implants
Baseline recording
When an implant is placed it is good practice for the dentist placing the implant
to take a baseline radiograph to record the bone level of the implant on
placement. This gives the team involved in caring for the implant a baseline to
work from for future assessment.
After the fit of the implant restoration, time should be allowed time for any
localized inflammation to subside. Once this has occurred, an appointment with
the hygienist or dentist should be scheduled to record base line parameters –
probing depths, bleeding on probing and plaque score. A modified version of the
original Sillness and Loe Plaque index has been produced by Mombelli et al,
along with a modified version of the Gingival Index (GI) and a simplified version
of the GI by Apse et al to help with the recording of these indices.
It is important to remember when recording a GI modified index that soft tissue
texture and colour around implants can depend on the normal appearance of the
tissue prior to placement, and that non keratinized tissue can appear to be
redder in colour than keratinized tissue. There have only been weak
correlations between GI scores and changes in peri-implant crestal bone levels,
in contrast to studies suggesting that an absence of BOP around implants is a
predictor of peri-implant health, and that BOP alone around implants yielded
higher diagnostic accuracy for peri-implant diseases at implant sites compared
with tooth sites.3
Table 1
Plaque Index – Mombelli et al
Score
0
1
No detection of plaque
Plaque only recognized by running a probe across the smooth
marginal surface of the implant
2
3
Plaque can be seen by the naked eye
Abundance of soft matter
Table 2
Gingival Index – Mombelli et al
Score
0
1
No bleeding when a periodontal probe is passed along the
mucosal margin adjacent to the implant
Isolated bleeding spots visible
2
3
Blood forms a confluent red line on the mucosal margin
Heavy or profuse bleeding
Table 3
Gingival Index – Apse et al
Score
0
1
2
3
Normal mucosa
Minimal inflammation with colour change and minor edema
Moderate inflammation with redness, edema and glazing
Severe inflammation with redness, edema, ulceration and
spontaneous bleeding without probing
Which ever index that we choose to use is not the concern, it is the regular
recording of clinical observations that is of importance. A suggested guide is to
record BOP around the implants at every visit and record ppd annually unless
there are signs of inflammation. If inflammation is present then the ppd must be
monitored more frequently until either inflammation has resolved or the patient
has been referred on.
Individual Homecare plans
An individual homecare plan should be developed at the initial appointment
after restoration fit with the hygienist/dentist. This allows the patient to know
exactly how they need to care for the implant. Teaching the patient how to
maintain the health of their implant is part of the duty of care that is expected
from a dentist placing implants. If the dentist does not wish to do this, this task
must be delegated to a member of his/her team as it is of vital importance in the
prevention of peri-implant diseases. As clinicians we cannot assume that a
patient will know how they must care for their new implant.
There is a variety of oral hygiene aids available for use for homecare of the
implant. In addition to brushing, the most popular aid for cleaning is the power
tip attachment for the braun toothbrush or a manual version of this (interspace
brush). This brush allows delicate cleaning and removal of biofilm from the
implant sulcus. These brushes can be modified by removing bristles with
scissors, making them thinner and more easily adapted to the implant sulcus.
Superfloss and Implant floss are both very good at removing the biofilm by
cleaning the neck of the implant due to the thickness and absorbing nature of the
floss. Interdental brushes and regular floss can also be used, but in my
experience interdental brushes alone will not control the biofilm, especially
around the buccal and lingual aspects of the implant so they need to be used in
conjunction with superfloss/floss. The air flosser by Phillips Sonicare and the
water irrigators available are also very good and most importantly, very easy for
patients to comply with.
Instruments to remove Biofilm around implants
There are many different types of instruments available on the market for
cleaning around dental implants. When considering your selection of instrument
to use around a dental implant you must take into consideration the effect that
the instrument will have on the surface of the implant. Due to this, standard
dental instruments are not recommended for this procedure.
Plastic instruments have been available for many years now but have the
disadvantage that they cannot be sharpened and are very bulky in nature.
Carbon instruments are also available, which are thinner than the plastic
instruments but again are not easy to maintain.
The hand instrument of choice to remove the biofilm from the implant is a
titanium instrument. These are widely available from the main manufacturers of
dental instruments including Deppeler, PDT and LM. The titanium instrument
has been shown to cause very little damage to the implant surface and can be
sharpened with a sharpening stone. It is however, important that the sharpening
stone that is used for this is kept solely for sharpening titanium instruments.
Ultrasonic tips are available with plastic inserts to use around the implant and
there are also ceramic tips now available for use with some of the piezo
machines.
Iatrogenic factors in Peri-implant disease
When a patient presents with peri-implant diseases we must look to see if there
are any other factors that may be influencing the condition. These include:




Excess cement around the implant
Abutments not fitting correctly
Design of restorations
Site of implant placement
Excess cement can be checked for by using some floss around the implant or by
using an explorer probe. If there is excess cement, it can be removed easily with
a hand instrument and the health of the gingivae should improve.
Abutments not fitting correctly can be checked on radiographs by the dentist
placing them and altered if necessary. The dentist placing the implants should
also take into account the design of the restoration in relation to allowing the
patient enough access to the implant so it can be cleaned on a daily basis with all
of the above mentioned oral hygiene aids.
Adjunctive treatments
When peri-implant diseases are detected, adjunctive aids can be considered for
use along side instrumentation. These include:
Amino acid glycine powder
Atridox
Dentomycin
Perio-chip
The amino acid glycine powder used in place of the sodium bicarbonate in the air
polishing systems has been shown not to change surface characteristics of
titanium implants4 with favourable treatment outcomes similar to that of subgingival root surface debridement with hand instruments.5
The EMS perio flow system comes with a disposable plastic nozzle, which can be
bent to give better access to pockets around difficult to reach implants.
Antibiotics also can be administered locally to areas of inflammation,
Dentomycin is the most popular that is used in practice. The antibiotics are most
effective when they are administered in conjunction with biofilm disruption in
the implant pocket.
Chlorehexidine has been shown to significantly reduce the bacterial load on the
surface of implants, and the placement of a perio-chip is relative easy around the
implant. It is always important to remember to inform patients that there may
be an initial localised swelling that lasts for 48 hours when a perio chip is placed
and that they need to avoid flossing for 10 days after placement as per
manufacturers instructions.
Before using any of the above in the treatment of peri-implant diseases the
hygienist should discuss each case with the referring dentist to determine a
treatment plan and gain a prescription (if required).
Summary
Peri-implant diseases are increasing in prevalence within daily practice and need
to be screened for when treating patients who have dental implants. Instruction
in how to care for dental implants needs to be given to patients immediately
after the implant has been restored and becomes functional. By delivering this
instruction when the implant becomes functional, disease processes can be
prevented.
References:
1. Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis.
Periodontal 2000 1998:17:63-76
2. Salvi, Lang. Diagnostic parameters for monitoring peri-implant conditions. Int
J Oral Maxiofac Implants 2004; 19 (suppl) 116-127
3. Jepsen S et al. Progressive peri-implantitis. Incidence and prediction of periimplant attachment loss. Clin Oral Imp Res 1996; 7: 133-134
4. Schwarz, F., Ferrari, D., Popovski, K., Hartig, B. & Becker, J. J. (2009) Influence
of different air-abrasive powders on cell viability at biologically contaminated
titanium dental implants surfaces. Journal of Biomedical Materials Research. Part
B, Applied Biomaterials 88, 83–91.
5. Moëne, R., Décaillet, F., Andersen, E. & Mombelli, A. (2010) Subgingival plaque
removal using a new air-polishing device. Journal of Periodontology 81, 79–88.