Post-Surgical Implant Care

Dental hygienists are key members of the oral care team in the post-treatment phase of implant therapy. The current scientific literature concludes that regular maintenance therapy with thorough debridement of biofilm and hard deposits is important for long-term implant health.^1—9 In 2013, the American Academy of Periodontology (AAP) reported that 6% to 47% of implants show evidence of peri-implant mucositis or peri-implantitis.³ Professional maintenance appointment intervals should be at least one time to four times per year to ensure early detection and treatment of inflammation around implants.^2,3,7 Jepsen et al¹⁰ found that 43.9% of patients with peri-implant mucositis who did not receive regular supportive care developed peri-implantitis, while only 18% of patients receiving consistent maintenance care progressed to peri-implantitis.

Current choices for the subgingival debridement of implants include plastic, filled resin, titanium-coated metal, or pure titanium hand instruments; sonic or ultrasonic scalers with plastic or resin inserts/tips; rubber cup polishing; and glycine powder air polishing (GPAP). Before maintenance therapy begins, however, implant status must be assessed, as it is critical to effective dental hygiene treatment planning. While probing of implants has always been controversial, research demonstrates that gentle probing does not damage the peri-implant tissues^1,4,11 and the use of a conventional metal probe may be acceptable on abutment surfaces.^5,12

If signs of inflammation are present, careful probing should be performed using either a plastic or metal probe with light force to assess tissue tone, bleeding or suppuration, and probing depths. In addition to probing, the examination must include mobility testing, occlusion assessment, and the taking of radiographs to detect evidence of bone loss. Analysis of these factors will determine the appropriate classification of implant status as described by Hempton et al.¹³ Table 1 includes a classification system (modified from Hempton’s original) to guide clinicians in the selection of appropriate treatment modalities.¹³

CLASS I: HEALTHY TISSUE

Healthy tissue around implants is firm, pink, does not bleed on probing, and is tightly adherent to the restoration. Well-maintained implants may have nonbleeding probing depths of ?5 mm, but they do not require aggressive or excessive subgingival instrumentation (Figure 1).

If the primary objective is biofilm removal, performing GPAP on implants provides effective bacteria removal with little or no alteration of the titanium surface.^14—16 Glycine is an amino-acid salt that is extremely fine, gentle, and safe for use on titanium implant surfaces and restorative materials. Glycine powder can be used supragingivally with a regular air polishing device and tip. Glycine powder is delivered subgingivally with a unique thin tip on a specially designed air polisher that uses half the air pressure of a conventional air polisher. Several comparative in vitro studies found that GPAP was superior to plastic or titanium instruments and implant ultrasonic inserts/tips (UITs) in debriding biofilm from implant surfaces.^17—20 GPAP does not, however, remove calculus or excess cement.

Rubber cup polishing with a nonabrasive toothpaste, tin oxide, or restorative polishing agent is an effective method for biofilm removal. Rubber cup polishing, however, may not extend as deep into the sulcus as subgingival air polishing, plastic or titanium hand instruments, or implant UITs.

Cleaning with floss or an implant oral hygiene cord may be helpful in removing biofilm during maintenance appointments. Also, some clinicians use the tip of a plastic probe or wooden toothpick tip secured to a handle to deplaque the sulcus with gentle, sweeping subgingival strokes.

CLASS II: PERI-IMPLANT MUCOSITIS

Peri-implant mucositis is the presence of inflamed tissue with bleeding on probing and ?5 mm probing depths but with no signs of bone loss. While the inflammation is generally a precursor to peri-implantitis, it can be resolved with thorough subgingival debridement of biofilm, calculus, and/or cement (Figure 2). Peri-implant mucositis is reversible when caught early.^1—6,21,22

GPAP and rubber-cup polishing are effective for biofilm removal, but neither will remove calculus or excess cement. Plastic implant instruments cause the least alteration of the titanium implant surfaces; however, they are limited in their ability to adapt to implant configurations and remove hard deposits effectively and efficiently. The blades of plastic instruments are usually thicker than metal instruments in order to maintain their rigidity. When using plastic instruments, gently insert the blade subgingivally and use short, overlapping, horizontal, oblique, or vertical strokes around the implant restoration. More options have been introduced to the plastic instrument arena, including smaller, thinner universal curet designs such as the Barnhart 5/6.

Titanium implant instruments offer thinner blades than do plastic instruments. Studies have shown, however, that they may create varying degrees of alteration to the implant surface.^23,24 Small titanium curets like the Barnhart 5/6 are available. The newest implant instruments include titanium Mini-bladed and Micro-mini-bladed Gracey curets that are easier to insert and adapt subgingivally due to their smaller working ends. Extreme caution must be taken when using titanium blades because they can damage the transmucosal seal and scratch the implant abutment.

Plastic hand instruments or plastic UITs cause the least amount of surface scratching compared to other types of implant instruments.^1—7 One study demonstrated that carbon fiber- and glass fiber-reinforced plastic blades can significantly scratch smooth implant surfaces.²⁴ Titanium instrument blades do not scratch implant surfaces as deeply as stainless steel, but they will cause damage if heavy pressure is applied.²⁵ Stainless steel instrument blades cause the deepest scratches and are not recommended.^1—6,25 Despite years of research showing in vitro and in vivo scratching of implant surfaces, literature reviews have concluded that roughened implant abutment surfaces caused by different instruments do not increase implant complications.^3,26,27

A plastic UIT that is thin enough to insert easily under the tissue and extend to the base of the sulcus is an alternative choice. Use short, overlapping, horizontal, and oblique sweeping strokes to disrupt biofilm and flush out debris with water. Studies have shown no additional therapeutic effect from the addition of antimicrobials as irrigants during ultrasonic scaling of implants or natural teeth.²²

If excess cement is present, do not attempt to remove it with implant instruments or implant UITs. Plastic and carbon fiber-reinforced plastic instruments are not effective for cement removal.²⁸ Attempts to remove cement with titanium or stainless steel instruments often cause gouging and damage to the implant surface.^3,6 The patient should be referred to the dentist who placed the restoration, a periodontist, or oral surgeon who can surgically expose the implant to gain access and remove the cement.^1—3

CLASS III: PERI-IMPLANTITIS

If peri-implantitis with severe inflammation, increased probing depths, bleeding on probing, suppuration, radiographic bone loss, exposed threads, calculus and/or cement, and mobility are present (Figure 3), referral to the dentist who placed the implant or a specialist is imperative. Mobility may be due to bone loss or loosening of the restoration. Peri-implantitis should be evaluated for contributory or secondary factors, such as residual cement and tobacco use, and proper interventions considered. Surgical intervention or endoscopic diagnosis and advanced treatment is required.^{1—3,29—31}

Current literature indicates that nonsurgical periodontal therapy for peri-implantitis is not effective.^{1—3,21,27,32} If gingival recession allows easy access to the first or second ex­posed threads, successful nonsurgical treatment may be possible. Using a dental endoscope enables clinicians to view and more effectively remove subgingival cement and calculus from the implant, possibly increasing the success of nonsurgical therapy.^29—31 Conventional scaling (without the aid of an endoscope) and irrigating failing implants are typically not enough to effectively treat peri-implantitis.^{1-4,21,22,26,32—34} Adjunctive therapies, such as subgingival irrigation or nonsurgical laser curettage, have limited or no significant long-term effects on peri-implantitis.^1—6,33,35 Several studies found the adjunctive use of local delivery antibiotics, photodynamic therapy, and Er:YAG laser debridement produced short-term reduction of inflammation.^{4,26,29,32,33,36,38}

Biofilm accumulation on residual cement as opposed to subgingival calculus is often the primary cause of peri-implantitis. Using a dental endoscope, Wilson²⁹ found that excess dental cement was associated with 81% of peri-implant disease cases and removal of cement led to resolution of disease in 74% of these same cases. This excess cement usually is very tenacious and cannot be completely removed by conventional subgingival scaling. The use of screw-retained crowns rather than cemented crowns eliminates this problem.

If the patient is not referred for surgical treatment, progression to severe peri-implantitis with implant loss is likely.^1—3 When an ailing implant can be viewed directly by flap surgery, laser surgery, or endo­scopy, cement and/or calculus can be removed with hand or ultrasonic instruments, burs, or lasers.^29—31 The contaminated titanium implant surfaces can also be air polished and treated topically with antimicrobials or antibiotics; systemic antibiotics also may be prescribed.

CLASS IV: FAILED IMPLANT

Implant failure is multifactorial and can occur early or late in the implant process. In addition to residual cement, some common factors are bacterial infection, improper surgical procedures, and occlusal overload. Suppuration and implant mobility with ongoing radiographic bone loss are classic signs of a failing implant (Figure 4).^1—3 A referral to the dental implant surgeon is absolutely urgent for a patient with these symptoms.

Table 2. Hand Instruments Designed for Use on Implants* Company Name Instrument Name Handle (Metal, Resin) Blade (Plastic, Titanium, Other) Available Designs (Universals, Graceys, Minis, Sickles, etc.) A. Titan Titanium Implant Scalers & Curettes Stainless Steel Titanium Tip(s) Gracey 1-2 TI , Gracey 11-12 TI , Gracey 13-14 TI , 204S TI , H6-H7 TI , BARN 5-6 TI , COL 13-14 TI , COL 4R-4L TI Titanium Implant Explorer Stainless Steel Titanium Tip(s) EXPL 5 TI , EXPL 23 TI Titanium Implant Probe Stainless Steel Titanium Tip UNC 15 TI American Eagle Instruments 204S Implant Scaler Resin Medical Grade Titanium Scaler Langer 3-4 Implant Curette Resin Medical Grade Titanium Curette Barnhart 5-6 Implant Curette Resin Medical Grade Titanium Curette Brasseler USA ImplantPro PEEK resin Solid 6Al-4V Titanium; never heat treated, which keeps Rockwell C hardness at a low 25-31 HRC Columbia 4R/4L , Langer 1/2, Langer 3/4, Langer 5/6 Hartzell Instruments (G. Hartzell and Son) Columbia, SA4L/4RSST Metal, ergonomic handle Titanium Universal Curette; choice of Handle designs Rigid Gracey, SAGL5/6SST Metal, ergonomic handle Titanium Gracey, Extended Gracey, Mini-Extended Gracey; choice of handle designs Rigid Gracey, SGL13/14SST Metal handle Titanium Gracey, Exteded Gracey, Mini-Extended Gracey; choice of handle designs LM-Dental Implant Mini Universal Curette (anterior/posterior) Medical-grade silicone Titanium alloy All of LM-Dental’s titanium implant instruments have replaceable tips (ErgoMix) Implant Mini Gracey 1/2 (anterior) Medical-grade silicone Titanium alloy All of LM-Dental’s titanium implant instruments have replaceable tips (ErgoMix) Implant Mini Gracey 11/12 (mesial) Medical-grade silicone Titanium alloy All of LM-Dental’s titanium implant instruments have replaceable tips (ErgoMix) Implant Mini Gracey 13/14 (distal) Medical-grade silicone Titanium alloy All of LM-Dental’s titanium implant instruments have replaceable tips (ErgoMix) Nordent Manufacturing, Inc. ImplaMate® Implant Maintenance Instruments DuraLite® ColorRing™ Hollow, Metal Handle Class 5 Titanium Tips N67 Anterior Sickle, 204S Posterior Sickle, N137M Anterior Scalette®, Barnhart 5-6 Curette, Langer Micro-Mini Curettes PDT, Inc. R900 Wingrove™ Titaniuniem Implant Maintenance Kit Resin Solid USA Medical Grade Titanium Universals Amazing Gracey™ Micro Mini Curettes Resin Solid USA Medical Grade Titanium Micro Mini Graceys: Gracey 1-2  , Gracey 11-12  , Gracey 13-14 Premier Dental® Products Company Implant Scalers Graphite Reinforced Resin Graphite Reinforced Resin Universal (4L/4R) , Facial (Goldman-Fox) , 137 , 204 Tess Oral Health 502 Implant Prophy Kit with Sharpening Stone Resin Autoclavable, re-sharpenable, plastic Kit Includes: • 1 Gracey 5/6 • 1 Gracey 11/12 • 1 Gracey 13/14 • 1 Columbia 13/14 104 Implant Instrument Resin Autoclavable, re-sharpenable, plastic Colombia Universal 13/14 101 Implant Instrument Resin Autoclavable, re-sharpenable, plastic Gracey 5/6 *This list is designed to be as comprehensive as possible, but there may be inadvertent product omissions.

CONCLUSION

Most hand and ultrasonic implant instruments are too large or too thick because they are most often copies of traditional instruments designed for natural teeth. The various configurations of implants, crowns, and prostheses pose unique challenges for subgingival instrumentation. Many hand and ultrasonic implant instruments do not adapt well and are too large or too flexible to remove calculus and/or cement effectively. Future research and development of new implant instrument designs are needed to improve clinical outcomes.

Effective implant maintenance is integral to the viability of this common therapy. While the rates of implant failure are low,³ clinicians need to remain up-to-date on advancements, such as dental endoscopy, GPAP, and new implant instrument designs, to ensure patients receive the best possible care.

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From Dimensions of Dental Hygiene. May 2015;13(3):24,26,28—29.