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Seeing implant treatment through to success

by: Dr. Paul S. Rosen

Proper maintenance care is an integral part of achieving success with every dental implant treatment.

Nd:YAG laser being used to treat peri-implant mucositis

Dental implants have a well-documented history of high success and survival rates. In fact, implants have in many instances become the “go to” treatment option when a tooth, or teeth, are experiencing problems that deem them hopeless. 

Nevertheless, complications can occur that can be either biologic or mechanical. The vast majority of dental implant problems, experienced during the maintenance phase of care, are related to inflammation. 

If the clinician is better able to identify and understand this, prevention and management can be performed more effectively. The importance of more stringent follow-up care for dental implants versus teeth is something that is oftentimes unrecognized and understated. Unfortunately, many patients have the erroneous belief that implants are immune to complications.

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The two major biologic complications encountered during the maintenance phase of care for dental implants are peri-implant mucositis and peri-implantitis. The former condition is one in which the inflammatory lesion is contained within the soft tissues surrounding the dental implant, and is not associated with crestal bone loss beyond that seen with physiologic modeling or remodeling of the hard tissues that occurs following implant placement and loading (Figures 1 & 2).

While this clinical condition has been called mucositis, it may be misleading because this inflammation can be present both in the presence and absence of keratinized tissue, i.e. gingiva. 

Peri-implantitis is often defined as the condition where bone has been lost around the dental implant due to the pathologic progression of inflammation (Figures 3 & 4).

It can threaten the survival of dental implants. It is of the utmost importance to distinguish between bone loss on the implant that is related to disease, as opposed to that associated with physiologic modeling/remodeling.

In order to determine if complications are beginning to occur, so that they may be intercepted at as early a moment as possible, it is important for the periodontist and restorative dentist to:

  • Identify risk factors associated with developing peri-implant diseases,
  • Establish a radiographic baseline at the time of implant placement, 
  • Establish a clinical and radiographic baseline at final prosthesis insertion, which includes periodontal probing where possible (Figure 5, below),
  • Design a tailored maintenance program that employs methods such as periodontal probing (wherever possible) that not only aids the patient in his or her hygiene efforts, but also monitors the stability of implant health and determines if inflammatory complications are beginning to occur, and
  • Establish an early diagnosis and intervention, which will contribute to more effective management of peri-implant diseases.

The question arises: What are some of the inflammatory risk factors about which we must be aware? 

From past and emerging evidence, smoking, uncontrolled diabetes, a history of periodontitis, and even a history of cardiovascular disease present an “inflammatory dysbalance” to the steady state around an implant. 

For patients with these factors noted in their medical or dental history, maintenance on an annual or even a semi-annual basis may not be enough. These patients may need to be seen at a more frequent interval, such as every 3–4 months to maintain a steady state of health. 

So, will standard brushing and flossing on the part of the patient along with the use of traditional hygiene instruments manage these problems? In some instances, yes, but not in every case.

Maintaining the peri-implant tissues in health is the responsibility of both the patient and the dental team (hygienist, restorative dentist, periodontist). Preventing the recurrence of inflammatory diseases involves ongoing plaque control and, where necessary, treatment that establishes a local environment to support this control. 

Initially, the patient’s plaque control techniques must be observed and possibly modified to a level deemed effective. When they are not, it must be determined whether these efforts fall short due to suboptimal effort on the part of the patient or less than ideal implant positioning due to ridge position or prior bone loss, where pink restorative materials may be needed to facilitate the esthetics, phonetics and function.

In these instances, adjunctive devices for homecare such as a Proxabrush® (Figure 6) (Sunstar Americas, Schaumberg, Illinois), an end-tufted brush, or a Waterpik® (Water Pik, Inc. Fort Collins, Colorado) may need to be considered whenever traditional brushing and flossing fall short of total plaque removal.

Moreover, antimicrobial rinses may also be necessary to reduce the bioburden that may develop and in some instances, it may be essential that the prosthesis be removed on a regular basis when the patient comes in for their maintenance visits.

Related: For a healthy start, always use a new healing abutment

For the treating hygienist, what tools are needed in the armamentarium to manage the peri-implant region? 

Debridement of the implant-supported restoration must be directed at three components: the prosthesis, the abutment, and the implant fixture, should its surface become exposed to the oral cavity. The restoration can be debrided, as with any other prosthesis, using appropriate instrumentation that avoids damaging the restorative material.

The restoration needs to be instrumented to remove any accumulated plaque and calculus biofilm or residual cement (Figures 7–9) while avoiding damage to the integrity of its smooth convex surface. No one approach accomplishes this goal in all situations and each scenario may require a customized approach to achieving a plaque- and calculus-free environment.

Utilizing conventional metal instruments designed for the natural dentition have been called into question as they have been shown to damage the implant abutment’s surface. Alternative options, depending on manufacturer guidelines, may involve air powder abrasion, specially designed sonic or ultrasonic instruments with padded tips; titanium and non-metal instruments manufactured for implant use; or perhaps dental lasers of specific wavelength(s) (Figure 10).

Non-metal instruments have demonstrated minimal or no damage to both machined and rough titanium surfaces with good adaptation to abutment surfaces. However, while plastic-coated scalers may cause minimal damage and may also have a polishing action, they can leave residual plastic deposits on the implant surface. 

Moreover, some of these instruments are too thick to gain access to areas requiring debridement. The take-home message is that no two implant prostheses are exactly alike and one needs to have a variety of instruments at her or his disposal to maintain a steady state of health. 

In summary, ensuring the long-term health of the dental implant is a team effort that includes coordination from the outset of care. If everyone plays his or her role in this enterprise, dental implants can maintain a healthy and highly satisfactory treatment that meets the patient’s goals.

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