Dental implant treatment has become standard clinical practice. The reliability and predictability of osseointegration in conjunction with improved soft tissue surgical procedures has led to an increasing number of patients seeking replacement of missing teeth with implant-retained prostheses.
In the UK about 150,000 implants are placed each year. This means that all general dental practitioners, as well as dental hygienists and therapists, will inevitably become involved in the maintenance of patients with dental implants.
It is a misconception to think that implant care commences after implant surgery; rather it begins long before.
The cause of tooth loss will vary from patient to patient and is usually due to one or more of the following: caries, failed previous restoration/s or periodontitis. From a periodontal context it is important to state that not all periodontally involved teeth should be extracted and replaced with implant-retained restorations.
While it is sometimes difficult to accurately predict the prognosis of some periodontally ’questionable’ teeth, traditional periodontal treatment can be used to treat moderate1 and even advanced cases of periodontitis2. Long-term studies of patients treated for periodontitis and maintained on a strict supportive periodontal care programme have confirmed that such treatment regimes can be very successful3,4,5,6. Indeed some studies have monitored and reported on the success of such treatment for as long as 22 years3.
While the success rates for implants in periodontally susceptible patients are acceptable (up to 90 per cent), the duration of such studies cover a mean follow-up period of 10 to 11 years7,8,9,10. The dental implant should not be considered a panacea, especially since recent evidence from the implant literature highlights the increasing problem of peri-implant diseases9,11 i.e. peri-implant mucositis (defined as inflammation of the peri-implant mucosa) and peri-implantitis (defined as peri-implant mucositis with associated peri-implant bone loss12,13).
Thus while implants are a good treatment option to replace missing teeth, they should never be used to ’treat’ periodontitis as this frequently leads to one problem (periodontitis) being replaced with another (peri-implantitis). Furthermore, while periodontal treatment can be successful, there is currently no reliable and predictable treatment for peri-implantitis14,15.
The aim of this article is to provide the general dental practitioner, hygienist and therapist with practical maintenance advice for patients who are about to undergo or who have received implant treatment.
The management of such patients falls into three phases:
a) before implant placement
b) during implant treatment phase
c) after implant restoration.
Patient management prior to implant surgery
A sound and healthy periodontium is an absolute prerequisite prior to implant surgery. An assessment of periodontal health should be performed in all patients. Indeed any routine oral examination performed by a dentist, hygienist or therapist should include a basic periodontal examination (BPE) as part of the soft and hard tissue examination16,17,18,19. This method of screening the periodontium will immediately detect underlying periodontal problems (Figure 1).
Periodontal disease must be treated prior to the patient receiving implant treatment. The removal of the dental biofilm forms the cornerstone of non-surgical periodontal therapy20 and this can be implemented in general dental practice.
A high standard of oral hygiene has to be achieved as poor oral hygiene has been shown to be a common risk factor for periodontitis and peri-implantitis21. After an active phase of periodontal treatment, which may also include periodontal surgery, the patient is enrolled on a supportive maintenance therapy (SPT) programme. This is different from the ’routine’ scale and polish and should be tailored to the patient’s needs. Other risk factors for peri-implantitis include a previous history of periodontitis and smoking, which also need to be addressed during this phase.
Patient management during implant treatment phase
Some patients might attend to see their dentist, hygienist or therapist during this healing phase either for a routine visit or possibly due to symptoms arising from the surgical site.
1. Bruising and swelling: most often patients have some degree of bruising or swelling in the immediate post-operative phase which is to be expected; the extent will vary between patients and between different surgical sites (swelling is usually more pronounced in the maxillary anterior region). Patient reassurance that the symptoms will subside after a few days is all that is needed in most cases. If however, the clinician is concerned about the risk of infection and possible wound breakdown, antibiotics need to be prescribed and the patient should be asked to see the surgeon who placed the implant.
2. Oral hygiene: patients are usually given verbal and written post-operative instructions (Figure 2). They are asked to refrain from brushing or flossing the surgical site in the immediate post-operative period (for two weeks after the surgery) and given a mouthwash to reduce bacterial load. After this period, oral hygiene is gently reintroduced using a soft toothbrush (for another two week period). Some toothbrush manufacturers have specific brushes intended for use during this phase. After this, the patient should be able to resume regular oral hygiene procedures.
3. Post-operative pain: post-operative analgesics are routinely prescribed for every patient, however at our practice, both surgeons find that patients are usually pleasantly surprised about the lack of pain after having had implant surgery.
4. Implant healing abutment or cap: there should be no attempt at removing or “testing” either the implant or healing components during this healing phase as the bone attachment to the implant surface is very immature and easily disrupted.
5. Suture removal: The patient is usually seen by the surgeon for a post-operative review and suture removal 10-14 days after the surgery. For those patients who are referred to another practice and who live a considerable distance from the latter, it might be more convenient for them to see their dentist for this first post-operative review appointment. The sutures used are resorbable or semi-resorbable and these will resorb in about 10-14 days. However, practical experience dictates that this varies between patients. If the sutures linger, the patient can start to find this irritating; provided the surgical site has healed well, the sutures can be removed by the dentist.
6. Temporary restoration during healing period: in the case of missing teeth in the aesthetic zone, most patients will have either a partial denture or bridge to temporarily restore the space during the healing period. These should not exert any pressure either on the implant or bone grafted area.
7. Sinus grafts: patients might experience a slight nosebleed on the day of surgery especially when bending forward; this is of no consequence. Patients are usually advised to sleep propped up with a couple of extra pillows on the day of the surgery and to avoid any increase in intra-nasal pressure e.g. nose blowing.
If there is any concern during this healing phase, the dentist is best advised to contact the surgeon who placed the implant.
Patient management following implant restoration
The high standard of plaque control achieved prior to implant surgery has to be revised and maintained post-surgery and applied to teeth and implants. The importance of this cannot be overemphasised if periodontal and peri-implant diseases are to be avoided. If the patient were enrol
led on a SPT programme prior to implant surgery, this will be standard practice (Figure 3).
The formation of dental biofilms on teeth or implants is very similar in their respective microbial compositions22. A pattern of disease similar in its initiation and progression to gingivitis and periodontitis has been observed in the case of peri-implant mucositis and peri-implantitis23,24. Clinical studies in animals have shown that during the same experimental time frame, the apical extensions of inflammatory connective tissue in peri-implant mucositis and peri-implantitis seem to be larger (i.e. extend more apically) compared with gingivitis and periodontitis respectively25,26. This is possibly because the connective tissue capsule, guarding the inflammatory zone and characteristically seen in gingivitis and periodontitis, is lacking in the tissues around implants.
Furthermore, in the case
of implants, the inflammatory lesion was seen to extend into alveolar bone implying a greater extension compared to the periodontitis lesion26.
The clinical implications of these findings signify that maintenance of peri-implant health is paramount and that early diagnosis of peri-implant disease is imperative; in the latter case treatment should be commenced without delay.
An assessment of the peri-implant tissues should be performed shortly after the implant is restored (baseline) and at every recall visit (Figure 4). Following a visual inspection of the soft tissues around the implant, the same diagnostic parameters used in periodontal reassessment are recorded namely:
a) peri-implant plaque
b) peri-implant probing depth
c) peri-implant bleeding on probing (BOP)
d) peri-implant suppuration
e) mobility of the implant
f) bone loss around the implant.
Probing around the implant using a metal or plastic probe should be performed using a light probing force (0.2–0.3N); this will not damage the junctional epithelium around the implant. A peri-implant probing depth up to 3mm and which does not bleed on probing signifies peri-implant health.
The only exception to this is a probing depth of up to 5mm interdentally in the aesthetic zone (interdental papilla). Provided there is no BOP and no increase in peri-implant probing depth compared to baseline, then this is accepted as being healthy. As is the case in periodontal reassessment, the absence of BOP is an indicator of stable peri-implant conditions27.
If peri-implant health is present, then no further treatment is required. The patient should be informed of the clinical findings and advised to continue with plaque control measures; prophylaxis of the implant (using a polishing cup and a nonabrasive paste), completes
the peri-implant and periodontal reassessment.
If BOP is detected around the implant with probing depths of 3mm, this signifies the presence of peri-implant mucositis i.e. a reversible inflammatory reaction in the soft tissue surrounding a functioning implant12 (Figure 5). Immediate action needs to be taken to prevent this progressing to peri-implantitis. Upgraded oral hygiene measures need to be demonstrated to, and implemented by, the patient; this includes flossing and brushing subgingivally around the implant. Any calcified deposits should be removed with non-metal instrument tips. If, in addition to BOP, peri-implant probing depths are in the range of 4-5mm, the additional use of chlorhexidine gel applied subgingivally twice a day for three to four weeks is advised after which the peri-implant tissues are reassessed. If health of the peri-implant tissues has been restored, then prophylaxis will suffice.
If BOP is accompanied with an increased peri-implant probing depth (>5mm) a radiograph needs to be taken; suppuration may or may not be present. Radiographic evidence of bone loss confirms the diagnosis of peri-implantitis12 (Figure 6). Treatment consists of improved oral hygiene techniques and use of chlorhexidine gel as outlined above and, in addition, antibiotics are prescribed if suppuration is evident; however since peri-implant surgery might be required when a diagnosis of peri-implantitis is made, such cases should be referred to a specialist without delay.
Mobility of an implant can present soon after implant placement signifying a lack of osseointegration. Alternatively it can arise as a late presenting feature confirming loss of osseointegration of the implant and the only outcome is removal of the implant. Pain around an implant is a rare and unusual presentation.
Radiographic examination following prosthesis installation and/or after one year in function, provides a baseline record of peri-implant bone levels. The inherent shortcomings of two dimensional imaging are that it lacks standardisation and detects bone loss in interproximal areas only. Follow-up radiographic investigation is indicated when peri-implant probing depths exceed 5mm.
All patients undergoing implant surgery at our implant clinic are assessed for periodontal health and any disease is treated accordingly prior to implant surgery. After the implant placement and prosthesis installation, a record of baseline parameters is noted on an implant maintenance record form before the patient is discharged back to the referring dentist. An implant assessment algorithm is enclosed with the record form (Figure 7).
Once an implant patient is discharged back to the dentist, the general dental practitioner, hygienist or therapist should provide an individually-tailored supportive maintenance care programme encompassing both periodontal and peri-implant reassessment in order to prevent initiation of disease or its recurrence. Some suggestions for a programme in general dental practice are:
1. patient education in continuing to maintain good periodontal and peri-implant health
2. the patient’s brushing and flossing techniques should be checked and revised accordingly
3. periodontal and peri-implant probing at each recall visit
4. professional plaque control measures and instrumentation as indicated by the clinical findings
5. planned recall visits, the frequency of which is based on patient’s susceptibility to disease
6. referral to a specialist if the patient’s treatment needs are out with the remit of the general dental practice.
The role of the dental hygienist or therapist in providing treatment and maintenance care is crucial. In the author’s opinion, hygienists and therapists should be involved in patient care prior to implant surgery as this highlights the importance of the patient maintaining a high standard of plaque control both before and after surgery. Furthermore it will facilitate the post-operative maintenance care programme.
About the author
Dr. Marilou Ciantar is a specialist
periodontist and oral surgeon at Blackhills Specialist Referral Clinic, Aberuthven, Perthshire. She welcomes referrals for periodontal treatment, implant surgery and oral surgery, including treatment under sedation for anxious patients. Marilou is also senior clinical teaching fellow in oral surgery at Aberdeen Dental School.
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