How Should Dental Implants be Maintained?

 

This is a question we are frequently asked by dentists and hygienists. It is critical to the survival of the implant that a routine maintenance regimen be adhered to.

To improve the long term success of implants, certain hygiene techniques, instrumentation and the use of antimicrobial agents are recommended.

A study of various oral hygiene instruments found that the interdental brush, plastic scaler and prophylactic cup all left the implant surface smooth, whereas the surface was severely roughened by ultrasonic instrumentation and metal curettes. Air powered abrasives, such as a prophy-jet, have been shown not to effect the implant surface, while effectively removing microorganisms. One must exercise caution not direct the pressured spray directly into the gingival cuff. Keeping the implant and abutment as smooth as possible is an important goal. A smooth surface tends to be less plaque retentive.

We recommend that minimal instrumentation be done on an implant demonstrating a healthy gingival attachment as evidenced by a lack of erythema or bleeding upon gentle probing. Remember, the soft tissues coronal to the implant-bone interface do not "attach" to the abutment head. At best, an adherent, soft tissue cuff is formed. The soft tissue adaptation or "cuff" is the only obstacle to the ingress of bacteria. [top]

It is important to remember that the patient may be hesitant to perform proper oral hygiene procedures in the implant area and that area must be considered weaker due to the lack of connective tissue fiber attachment. Therefore, subgingival instrumentation is rendered judiciously. We can supply you with names of vendors who manufacture instruments acceptable for debridement of this delicate interface.

Applications of antimicrobials result in no alteration of the implant surface. One effective means of maintaining soft tissue health around the implant is the use of a rinse such as a chlorhexidine(Peridex or Periogard), chlorine dioxide (OxyFresh), or a phenolic product (Listerine). At home, hygiene may also benefit from the use of interdental brushes or uni-tufted brushes. A dentifrice containing triclosan (Colgate-Total) is now available and would be advisable. If retrievable, the superstructure should be removed at least every 18 to 24 months. This will afford an improved access for debridement and accurate assessments of probing depths and mobility. Additionally, regular radiographs are advisable to check for cratering. [top]

Treatment for Failing Implants:

Two Failing H.A. Coated Implants:

1. A.--- A circumferential bony crater.
2. B.--- Alveolar bone.
3. C.--- HA coated implant with calculus.

Failing dental implants usually display the clinical characteristics of periodontally diseased teeth. Progressive bone loss, pocket formation, bleeding upon probing, and purulence are some of the findings you may notice. Successful and prompt management of the failing implant is critical to prevent the implant loss. A failed implant is one that displays mobility, has lost it's osseointegration and has a hopeless prognosis. Since failed implants are functionless they should be removed so that the alveolar defect can fill.

The subgingival microflora around a failing implant is similar to that found around periodontally diseased teeth. Therefore, the implant surface affected by peri-implantitis is contaminated by bacterial products , such as endotoxins, that can interfere with biologic repair.

One must realize that a failing implant will soon become a failed implant if intervention is not attempted. The same caution employed to minimize the roughening of the implant and abutment is thus considered to be less important than the thorough debridement of the effected surfaces. Calculus is often present, especially on hydroxylapatite coated implants. It has to be removed completely. Curettes and ultrasonic instrumentation is often employed. [top]

Chemical disinfection has been researched to remove the endotoxins. Chlorhexidine, citric acid, hydrogen peroxide, stannous fluoride, sterile saline and tetracycline are some of the agents which have been studied. The clinical efficacy of any of these agents remains to be ellucidated.

Usually, these debridement procedures have to be accomplished by open flap procedures. Adequate access is extremely important to effectively debride and detoxify the implant and abutment. Also, this affords the opportunity to remove any inflamed granulation tissue around the implant.

If the peri-implant supporting bone is severely cratered, bone regeneration may be attempted if the implant has not yet lost it's integration. We advise removing the super-structure and replacing the small healing screw. This will allow the soft tissue to grow over the implant such that a primary closure of the soft issue flaps is easily accomplished. Bone regenerative techniques are employed usually by placing allograft bone into the defect and covering the implant with a resorbable guided tissue regeneration membrane. We advise not loading the implant until the bone repair is completed. Usually three months is required for maturation.

Finally, by definition, a failed implant is one which has lost it's integration. Unfortunately, at this point, removal is the only solution. If in the future, the patient is interested attempting another implant, bone regenerative methods may be employed at the time of removal and may provide an adequate placement site after an adequate healing period has passed. [top]