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Implant Maintenance Protocol by Dr. Thanos Ntounis, DDS, MS & Dr. Lillie Pitman, DMD

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Header: Implant Maintenance Protocol
by Dr. Thanos Ntounis, DDS, MS & Dr. Lillie Pitman, DMD

Introduction
Dental implants have changed dentistry.

Several studies on dental implants indicate high success rates—in the upper 90th percentile. We need to bear in mind that these studies take place in highly specialized centers around the world. In the real world, complications are far more common.1,2

Interestingly, a recent study published in The Journal of American Dental Association showed a 19 percent failure rate of implants placed in general-dentistry practices.3 Most of these complications can be attributed to surgical, restorative and treatment-planning errors. A number of studies emphasize the high prevalence of biologic complications of peri-implant mucositis and peri-implantitis, inflammatory conditions in the soft and hard tissues at dental implants.4-6 In this article we will review the current knowledge concerning peri-implant mucositis and peri-implantitis.

Recent data shows that at least 50 percent of all subjects with implants suffer from some form of peri-implant pathology.7 It is our responsibility as periodontists to prevent peri-implant disease. This obligation is not only moral, but also financial. Replacing failing implants is extremely costly for both the clinician and the patient. This article is an effort to establish an organized protocol for maintenance of our implant patients.

Who is responsible for implant maintenance?
Everybody who is involved in the patient's care shares equal responsibility in establishing a maintenance protocol. This includes the surgeon, the restoring dentist and the hygienist.

Upon delivery, the restoring dentist should:
  • Ideally use a radio-opaque cement in the case of cement-retained restorations.8
  • Follow a clinical protocol that eliminates excess cement at cementation (Figs. 1-4).9
Figs. 1-4

After delivery, acquire a baseline radiograph that can be used to evaluate possible future changes. The radiograph should be perpendicular to the crest as well as the prosthetic margin. A good guide to make sure that you acquired a good radiograph is whether you can see all of the implant's threads, peaks and valleys. Figure 5 demonstrates a proper radiograph (Fig. 5).

The examiner needs to be able to differentiate and diagnose peri-implant diseases. For the purpose of this protocol, diagnosis classification follows the American Academy of Periodontology report: "Peri-Implant Mucositis and Peri-Implantitis: A Current Understanding of Their Diagnoses and Clinical Implications" (http://www.joponline.org/doi/pdf/10.1902/jop.2013.134001).
  • Peri-implant mucositis has been described as a disease in which the presence of inflammation is confined to the soft tissues surrounding a dental implant with no signs of loss of supporting bone following initial bone remodeling during healing.5
  • Peri-implantitis has been characterized by an inflammatory process around an implant, which includes both soft-tissue inflammation and progressive loss of supporting bone beyond biological bone remodeling (Figs. 6 & 7).5
  • According to recent data, 80 percent of the subjects (50 percent of sites) are diagnosed with peri-implant mucositis, while 28 percent to 56 percent of the subjects (12 percent to 40 percent of the sites) are diagnosed with peri-implantitis.7


    • Figs. 5-7

  • During probing, implants are to be probed as often as teeth, and in the same visit. Pocket depths are recorded. The pocket depths are used to evaluate the long-term stability of the area and are compared with previous recordings. Due to the fragile nature of the peri-implant architecture, the recommended probing force is 0.15N. Clinically, this corresponds with applying light force.10 The hygienist needs to be trained and calibrated with the dentist on this subject.
  • Every other index that is used around teeth is also recorded for implants (PD, GM, CAL, BOP, plaque or suppuration).5 For the CAL measurement, the crown margin may be used as a point of reference, instead of the cement-enamel junction.
  • The actual pocket depth is of limited value. It is the change that allows for diagnosis of peri-implant pathology.5
  • For probing, a plastic probe is suggested, mainly because it allows for flexibility around the prosthetic components. The use of a metallic probe is acceptable.11 There is no evidence to suggest that probing with a metallic probe damages your implants.10 In fact, in Europe it is common practice. It is the authors' opinion that on implants with platform switching, the use of a flexible plastic probe allows more accurate measurement.
What about the radiographic examination?
  • After delivery, acquire a baseline radiograph that can be used to evaluate possible changes in the future. The radiograph should be perpendicular to the crest as well as the prosthetic margin.
  • If no signs and symptoms of disease are present, then additional radiographs can be obtained at the same time with healthy dentition.
  • If there are signs and symptoms of disease, such as bleeding, suppuration, pain, mobility or pocket depth increase, a radiograph should be acquired to assist with the diagnosis.
  • Radiographs are confirmatory instead of exploratory, and should be considered in conjunction with clinical parameters (Fig. 8).
What are the best instruments for use during maintenance visits?
  • The research is ongoing on this field.
  • Titanium scalers are acceptable for implant debridement. Some plastic scalers leave remnants in the tissues when used against roughened implant surfaces.12 Currently, there is no evidence on the effect of plastic instrument remnants around implants.
  • A soft-tip plastic sleeve placed on the tip of a sonic or ultrasonic scaler can be used, and does not damage the abutment and crown surface.13 Debridement of micro- or nano-roughened implant surfaces with conventional mechanical scaling is ineffective.14


Maintenance visit considerations
Implant patients tend to be more compliant than other patients.15 Consider increasing recall visits of implant patients to four times a year, especially in the presence of risk factors such as diabetes, smoking and history of periodontal disease.

The dental hygienist should be competent in preventing and recognizing peri-implant disease, treating, and referring to a periodontist.16 In the event of diagnosis of peri-implant mucositis, nonsurgical treatment should take place with oral-hygiene instructions, localized debridement and possible use of chemotherapeutic agents such as chlorhexidine gluconate.7

Treatment of peri-implant mucositis should be provided in all of the settings, including hygiene.

At this point the patient is considered to be under active treatment, and a re-evaluation visit should be scheduled within 4-6 weeks.

In the event of diagnosis of peri- implantitis, nonsurgical treatment has been shown to be ineffective, and referral should take place.17-19 What about the soft tissue, or is there an elephant in the room?
Studies remain ambivalent on the importance of attached keratinized peri-implant mucosa.20

Despite that, our long-term clinical experience and observation have shown that, in patients who present with a multitude of hygiene challenges (e.g., hybrid restorations, or cemented prostheses with deeper margins) the presence of a solid band of attached peri-implant mucosa becomes crucial.

Such a zone will allow the patient to clean more effectively, since the tissues will be less movable. Additionally, it will also withstand mechanical cleaning and oral hygiene without any sensitivity, unlike buccal or labial oral mucosa. We have found that the great majority of implants with peri-implantitis present with poor mucosal architecture and lack of attached tissues (Fig. 9, p. 100).

In order to improve the quality of the surrounding tissue, grafting procedures—such as modified apically positioned flaps, free gingival grafts or use of allogenic matrix grafts (Figs. 10-15)—can take place.

Figs. 9-12



Figs. 13-15

These procedures can ideally take place prior to implant placement, although often they can be performed after implant placement, or even after restoration (Figs. 13-15).

During hygiene visits, it is important to note the condition of peri-implant mucosa, and a persistent problem of inflammation should be addressed by referral to a periodontist. In combating peri-implant diseases, what is considered the "golden hour" to avoid a surgical procedure is upon diagnosis of peri-implant mucositis. That is when the condition is reversible.21

References
  1. Charyeva O, Altynbekov K, Zhartybaev R, Sabdanaliev A. Long-term dental implant success and survival--a clinical study after an observation period up to 6 years. Swed Dent J 2012;36(1):1-6.
  2. Estafanous EW. Dental implant success in challenging situations? Int J Oral Maxillofac Implants 2013;28(6):1455-9.
  3. Da Silva JD, Kazimiroff J, Papas A, et al. Outcomes of implants and restorations placed in general dental practices: a retrospective study by the Practitioners Engaged in Applied Research and Learning (PEARL) Network. J Am Dent Assoc 2014;145(7):704-13.
  4. Klinge B, Hultin M, Berglundh T. Peri-implantitis. Dental Clinics of North America 2005;49(3):661-76.
  5. Sanz M, Chapple IL, Working Group 4 of the VEWoP. Clinical research on peri-implant diseases: consensus report of Working Group 4. J Clin Periodontol 2012;39 Suppl 12:202-6.
  6. Simonis P, Dufour T, Tenenbaum H. Long-term implant survival and success: a 10-16-year follow-up of non-submerged dental implants. Clin Oral Implants Res 2010;21(7):772-7.
  7. Lindhe J, Meyle J, Group DoEWoP. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008;35(8 Suppl):282-5.
  8. Antonijevic D, Obradovic-Djuricic K, Rakocevic Z, Medigovic I. In vitro radiographic detection of cement overhangs on cement-retained implant restorations. Int J Oral Maxillofac Implants 2013;28(4):1068-75.
  9. Chee WW, Duncan J, Afshar M, Moshaverinia A. Evaluation of the amount of excess cement around the margins of cement-retained dental implant restorations: the effect of the cement application method. J Prosthet Dent 2013;109(4):216-21.
  10. Etter TH, Hakanson I, Lang NP, Trejo PM, Caffesse RG. Healing after standardized clinical probing of the perlimplant soft tissue seal: a histomorphometric study in dogs. Clin Oral Implants Res 2002;13(6):571-80.
  11. Schou S, Holmstrup P, Stoltze K, et al. Probing around implants and teeth with healthy or inflamed peri-implant mucosa/gingiva. A histologic comparison in cynomolgus monkeys (Macaca fascicularis). Clin Oral Implants Res 2002;13(2):113-26.
  12. Yang SM, Park JB, Ko Y. Use of confocal microscopy for quantification of plastic remnants on rough titanium after instrumentation and evaluation of efficacy of removal. Int J Oral Maxillofac Implants 2015;30(3):519-25.
  13. Kawashima H, Sato S, Kishida M, et al. Treatment of titanium dental implants with three piezoelectric ultrasonic scalers: an in vivo study. J Periodontol 2007;78(9):1689-94.
  14. Schwarz F, Hegewald A, John G, Sahm N, Becker J. Four-year follow-up of combined surgical therapy of advanced peri-implantitis evaluating two methods of surface decontamination. J Clin Periodontol 2013;40(10):962-7.
  15. Cardaropoli D, Gaveglio L. Supportive periodontal therapy and dental implants: an analysis of patients' compliance. Clin Oral Implants Res 2012;23(12):1385-8.
  16. Ward ST, Czuszak CA, Thompson AL, Downey MC, Collins MA. Assessment and maintenance of dental implants: clinical and knowledge-seeking practices of dental hygienists. J Dent Hyg 2012;86(2):104-10.
  17. Lang NP, Berglundh T, Working Group 4 of Seventh European Workshop on P. Periimplant diseases: where are we now?--Consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol 2011;38 Suppl 11:178-81.
  18. Schou S, Berglundh T, Lang NP. Surgical treatment of peri-implantitis. Int J Oral Maxillofac Implants 2004;19 Suppl:140-9.
  19. Sanz M, Lang NP, Kinane DF, et al. Seventh European Workshop on Periodontology of the European Academy of Periodontology at the Parador at la Granja, Segovia, Spain. J Clin Periodontol 2011;38 Suppl 11:1-2.
  20. Wennstrom JL, Derks J. Is there a need for keratinized mucosa around implants to maintain health and tissue stability? Clin Oral Implants Res 2012;23 Suppl 6:136-46.
  21. Schwarz F, John G, Hegewald A, Becker J. Non-surgical treatment of peri-implant mucositis and peri-implantitis at zirconia implants: a prospective case series. J Clin Periodontol 2015.


Dr. Thanos Ntounis Dr. Thanos Ntounis is a dual specialist in the fields of prosthodontics and periodontics. He received his DDS from the University of Athens Dental School in Athens, Greece, in 2005. He went on to complete a prosthodontics residency and a master's degree from the same institution (2006-2009). Ntounis completed his periodontics residency at the University of Alabama at Birmingham (UAB) and the Birmingham Veterans Affairs Hospital (2010-2013). After being awarded a fellowship from the UAB Graduate School, he completed a second master's degree in clinical dentistry, researching the effect of growth factors on ridge preservation. Dr. Ntounis is board-certified by the American Board of Periodontology and has published several peer-reviewed papers in the field of implant dentistry. He currently practices with his wife, Dr. Lillie Pitman, in their private practice limited to periodontics and implants in Fredericksburg, Virginia.
Dr. Lillie Pitman Dr. Lillie Pitman practically grew up in a periodontal office in northern California, where her mom was a dental assistant. She received her DMD and certificate in public health from the Arizona School of Dentistry and Oral Health in 2011. Always knowing she wanted to be a periodontist, she went on to complete a periodontics residency at the University of Alabama at Birmingham (UAB) and the Birmingham Veterans Affairs Hospital (2011-2014). Pitman was presented one of the most prestigious awards given by the American Academy of Periodontology Foundation, the Gerald M. Kramer Scholar Award for Excellence. Pitman achieved board certification by the American Board of Periodontology in 2015. She practices with her husband, Dr. Thanos Ntounis, in their private practice limited to periodontics and implants in Fredericksburg, Virginia.



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