How to Preserve, Protect, and Defend Dental Implants

To find out more about the essential basics of maintaining healthy implants, Inside Dental Hygiene speaks with two experts—an implant surgeon and professor, and a hygienist whose resume includes many years working at a practice centered around implants. Whether you encounter one implant per day in your own scope of work or a dozen, this article is intended for you. Let's learn more.

All hygiene care is important. For patients with dental implants, that care is even more crucial. Healthy, well-maintained implants can last a lifetime, but if disease sets in, an entirely different picture emerges. There are two types of peri-implant disease: peri-implant mucositis and peri-implantitis. Peri-implant mucositis, similar to gingivitis in natural teeth, is defined as inflammation without attachment loss or bone loss.⁴ Peri-implantitis, on the other hand, is the more severe form of peri-implant disease that is comparable to periodontitis in natural teeth and is defined as inflammation that has progressed to the point at which tissue breaks down.⁴ Risk factors for peri-implant disease include smoking, a history of diabetes, and poor home care.⁴ Furthermore, peri-implant diseases progress faster than disease around natural teeth and can be difficult to treat.^5,6 It also can develop years after a patient has received an implant.⁷ With these factors in play, monitoring patients who have implants for early signs of inflammation is highly recommended.

"It's critically important that we surveil implants more frequently and more rigorously than we even would for teeth," says Mia L. Geisinger, DDS, MS, an implant surgeon and a Professor in the Department of Periodontology at the University of Alabama at Birmingham. That surveillance, Geisinger says, involves measuring and recording patient data and tracking it over time. "We want to make sure we have excellent baseline data that includes good radiographs where we can clearly see the threads of the implant and the crest of the bone and baseline probing depths, even though probing depths are not predictive in the same way they are around teeth. A 5 mm or a 6 mm probing depth can be healthy around an implant, but any increase in that probing depth or bleeding upon probing can indicate that something is going awry with that implant."

"Documenting that baseline data when the restoration is performed is essential, so that we can develop a monitoring and a maintenance schedule based upon the patient's individualized risk factors," Geisinger says.

In general, most patients with implants, even those with healthy soft tissue, can often benefit from more frequent hygiene visits than patients without implants-even if shorter intervals between appointments requires extra out-of-pocket expenses for the patient.⁸

"As an implant surgeon, I explain to my patients the importance of maintenance, and I say, ‘You're investing in a really expensive piece of equipment,'" Geisinger says. "If you have a high-end luxury car, you may need to take it to the dealership more frequently, and you certainly make sure you're getting the right kind of oil and top-notch checks on that car. You're also changing your tires so that you continue to have optimum performance. The same principle is true with an implant, and the more sophisticated the implant restoration is, the more imperative frequent maintenance becomes."

"A fixed hybrid or full-arch restoration where you have multiple implants that are tied into a single bridge can require more ongoing maintenance to make sure that the patient stays in a healthy state," Geisinger says.

When Stephanie Pajot, RDH, first sees a patient with one or more dental implants, she begins with an assessment. "I first evaluate why this patient has lost the tooth or the teeth to begin with, because if the cause is linked to periodontitis, such as a family or patient history of systemic disease, like diabetes or heart disease, or if the patient has a habit such as smoking or poor home care, all of those things can also contribute to peri-implantitis," says Pajot, whose career as a hygienist includes many years working at a practice geared toward implant treatment. "If there's an underlying periodontal issue that we couldn't stabilize before the tooth was lost, then we're at the same risk with an implant," she says. "Bone loss occurs faster around an implant than a natural tooth, and that's one of the first things I point out to a patient who has recently had an implant placed."

A frank discussion with the patient is often needed. "I try to stress that a dental implant isn't a ‘free pass' unfortunately. No, they won't get a cavity, but the implant can still fail," Pajot says. "It's hard to break bad habits, so if the patient isn't willing or able to quit smoking, for example, I gently inform them that they're at a higher risk for losing their implant and maybe we need to see them in the office more frequently than every six months."

Those who have received implants after losing teeth from other causes, such as the result of a cracked tooth from trauma, are often better positioned for long-term success, Pajot says. But even then, she emphasizes, regular hygiene visits and home care are essential. "We need to make sure all patients, and especially those with implants, are coming for their hygiene visits regularly," Pajot says. "It's a case-by-case basis how often they need to be seen."

When patients with implants come in for their visits, Pajot says, it's always helpful to do some investigation. "If they say it feels like nothing, that's usually a good sign," she says. "If they have pain, I really listen because implants don't typically cause pain unless something is going wrong. I will evaluate the surrounding tissues. Is it red? Is it pink? Is it rolled or firm? Is it bleeding or is it not? Is there calculus, plaque, cement, or food debris in the pocket? Is the occlusion correct? Then the radiographs will tell us more of the story."

When it comes to instrumentation, it's important for hygienists to select equipment that is safe for implants. "I prefer titanium by a long shot over plastic because plastic instruments don't provide the sharpness, or a working end narrow enough to remove calculus," Pajot says. "I'm a fan of the Paradise Dental Technologies Amazing Gracey Titanium Extended Reach Micro Mini hand instruments or an ultrasonic insert designed for implants."

"At the first sign of inflammation, I will recommend laser bacterial reduction (LBR) with a diode laser to disinfect the pocket around an implant," Pajot says. "LBR will not remove calculus and plaque, however the laser is able to destroy microscopic bacteria once scaling has been completed. This treatment is affordable and doesn't require the need for medication."

Geisinger says that because implants are made of titanium, which is a notoriously soft metal, or titanium alloys, which are softer than stainless steel, instrumentation must be specific for implants and designed for maintaining the surface integrity of the implants and the abutments. "Moving to soft titanium instrumentation is beneficial," she says. "When it comes to professional tools for plaque control, there are some excellent options including ultrasonic scalers with specific implant tips made of silicone or appropriate grade titanium that can be used around implants. We also have air polishing systems with materials designed for implants themselves."

When performing hygiene care on implants, technique comes into play a great deal. "With implants I tend to use more horizontal strokes than I would on natural teeth," Pajot says. "We must be more creative when cleaning implants, especially implant bridges or full arch cases. We are faced with a big, bulbous crown on a skinny little stem, making access difficult. I also consider using posterior instruments for the anterior region, and vice versa. We need to decide which instrument will best adapt to the site at hand." A light touch is also key, Pajot adds. "Preventing damage to the fibers that are so critical for implant attachment is imperative," she says.

Another concern for patients with implants relates to crown placement. "We know residual cement can be a cause for developing peri-implant disease, and it can occur up to nine years implant crown cementation," Geisinger says. "Hygienists are often the first ones to see that and to identify the cement. The newer cements are radiolucent, but a hygienist who is instrumenting gingerly can often feel that there is something hard and rough on the implant surface. Calculus is generally easy to remove, so if something is not easily removable it could be cement."

Pajot says she has encountered cement when treating patients with implants. "It is important for hygienists to remove any excess cement because this can provide surface area for bacteria to grow, which can be detrimental," Pajot says. "It's a delicate balance to thoroughly clean implant threads while avoiding damage to the implant. Scratching the implant can equate to a new highway for bacterial growth." If it is a screw-retained crown, Pajot uses a mini screwdriver to tighten it for the patient in order to avoid any crown movement. "I like to tighten everything up before the doctor comes in for the exam," she says.

Pajot says she doesn't see a huge advantage to probing unless she finds something is wrong. Instead, she will observe the tissue and radiograph. "If the implant seems happy, I will do my regular periodontal charting for the whole mouth, and, per the doctor, I will skip the implants," she says. "The probing depth is often skewed due to implant anatomy and the probing angle required for insertion. The collagen fibers that bond the implant to the tissue are very delicate. We need to prevent fiber damage as well as prevent introduction of new bacteria from the tip of the probe down into the pocket."

Before implant patients are sent on their way, the discussion about at-home maintenance is especially important. "Home care is huge for patients with implants," Pajot says. "I will recommend a power toothbrush, and, if the patient is sensitive, they should use the gentle setting. I also like to recommend water flossers, but for implant patients I advise using them at the lowest setting. From there, it just depends on the anatomy of the patient."

Pajot also recommends dental tape over thick woven floss for patients with tight spaces between implants and natural teeth as well as interdental brushes that are the correct size. She shows her patients examples, so they know what size and kind to purchase.

Geisinger advises that traditional dental floss may be less helpful except for single tooth implants, in which case a shoe-shine technique of wrapping the floss around the implant may be advantageous. For patients using powered water flossers, Geisinger says, it is important to position the water stream perpendicular to the long axis of the implant rather than parallel, because if a patient puts a water jet parallel to the implant, it can dislodge the attachment apparatus. "I always say it's like a Velcro around implants versus a zipper around teeth," she says.

According to Geisinger, interdental cleaning is particularly important when patients have long span fixed partial dentures or fixed detachable FP3 restorations, which can be more difficult to get underneath.

Geisinger recommends toothpastes and mouth rinses with neutral pH. She cautions that prescription mouth rinses containing chlorhexidine can increase the amount of titanium dissolution products and should not be used around implants for extended periods.

Patients with implants have likely undergone many months of treatment and invested considerable financial resources to get where they are now. It would be a shame if anything were to happen to jeopardize the progress they have made. With the right amount of hygiene care, combined with routine and adequate home care, those implants can last and last.

"Hygienists are really on the front lines. They are seeing the patients and watching for signs and symptoms of inflammation, or seeing the plaque control before they start that cleaning, so they have a really good idea of what the risk factors may be individually for each patient," Geisinger says. "Implants are great restorations, but they require a different techniques and frequency of maintenance care compared to teeth, and that's OK."