Before, during, and after restoration
by Susan Wingrove, RDH
Good oral hygiene must take place before, during, and after
placement of dental implants to ensure the health of the implant.
Patients are concerned about what kind of maintenance their
implants will require. Do they brush and floss their implants like
regular teeth? Does food get underneath the fixed implant bridge
or prosthesis? Patients look to their hygienists to address these
concerns and help them with an individualized home-care routine.
The tissue surrounding the implant should appear pink, firm, and keratinized
with no signs of infection. The peri-implant soft tissues (permucosal seal) that
separates the connective tissues surrounding the implant from the outside
environment should be keratinized tissue . The absence of
keratinized tissue has been documented to be more susceptible to pathogenic
bacteria thus leaving the implant vulnerable to peri-implant disease. The
success of the implant depends directly on the health of this seal, and the
hygienist's goal is to educate the patient on how to obtain keratinized tissue
and maintain a healthy permucosal seal.
with no signs of infection. The peri-implant soft tissues (permucosal seal) that
separates the connective tissues surrounding the implant from the outside
environment should be keratinized tissue . The absence of
keratinized tissue has been documented to be more susceptible to pathogenic
bacteria thus leaving the implant vulnerable to peri-implant disease. The
success of the implant depends directly on the health of this seal, and the
hygienist's goal is to educate the patient on how to obtain keratinized tissue
and maintain a healthy permucosal seal.
| Figure 1: Keratinized tissue surrounding the implant. Courtesy of Dr. Robert Horowitz |
This reinforces the point that home-care must begin immediately and, if
possible, before the implant is placed to maintain a healthy field and for
optimal healing.
possible, before the implant is placed to maintain a healthy field and for
optimal healing.
Once the implant is exposed to the environment, loaded (occlusal forces)
and restored a salivary pellicle is formed followed by
bacteria with the formation of biofilm. The elimination of 85% of
plaque/biofilm on a daily basis is critical to the overall health of the implant.
and restored a salivary pellicle is formed followed by
bacteria with the formation of biofilm. The elimination of 85% of
plaque/biofilm on a daily basis is critical to the overall health of the implant.
Hygienists can prepare patients by providing home-care recommendations
based on the individual treatment case. This begins with post-surgical
home-care guidelines to ensure the patient feels comfortable and confident
until they return for routine implant maintenance. Always verify
recommended guidelines with the implant surgeon's recommendations.
based on the individual treatment case. This begins with post-surgical
home-care guidelines to ensure the patient feels comfortable and confident
until they return for routine implant maintenance. Always verify
recommended guidelines with the implant surgeon's recommendations.
| Figures 2a, b: Placement of an implant. Courtesy of Keystone Dental |
Knowledge of the implant titanium surface is necessary to fully understand
what oral hygiene recommendations and products to present to patients.
After 1990, a definite switch from smooth titanium alloy surface to a rougher
implant surface transpired, which has proven to accelerate osseointegration.
The addition of surface coatings to create roughness with plasma spraying,
grit blasting, and etching has also proven to raise the bone-to-implant contact
and accelerate osseointegration.
what oral hygiene recommendations and products to present to patients.
After 1990, a definite switch from smooth titanium alloy surface to a rougher
implant surface transpired, which has proven to accelerate osseointegration.
The addition of surface coatings to create roughness with plasma spraying,
grit blasting, and etching has also proven to raise the bone-to-implant contact
and accelerate osseointegration.
To help the patient protect their implant(s), their investment, patients need
to be aware of the following key points on choosing safe home-care products.
First the product (for example, toothpaste or gel) needs to be low-abrasive to
not scratch the surface of any exposed surfaces of the implant (exposed threads,
for example). Avoid dentifrice with stannous fluoride, sodium fluoride (APF >3.0),
baking soda, stain removers, and smoker's toothpaste.
to be aware of the following key points on choosing safe home-care products.
First the product (for example, toothpaste or gel) needs to be low-abrasive to
not scratch the surface of any exposed surfaces of the implant (exposed threads,
for example). Avoid dentifrice with stannous fluoride, sodium fluoride (APF >3.0),
baking soda, stain removers, and smoker's toothpaste.
Companies are researching low–abrasive dentifrices that are effective yet safe
for implants, natural teeth, and completely edentulous implant patients
(Colgate, Procter & Gamble, and Rowpar among others). Ramberg et al.
reported that Colgate Total in a double-blind, randomized, parallel-group
clinical (in vivo) trial with 59 participants concluded that brushing with Colgate
Total twice daily reduces bleeding on probing adjacent to implant sites in a
three- and six-month period with proven results of reducing plaque bacteria
to help prevent peri-implant disease.
for implants, natural teeth, and completely edentulous implant patients
(Colgate, Procter & Gamble, and Rowpar among others). Ramberg et al.
reported that Colgate Total in a double-blind, randomized, parallel-group
clinical (in vivo) trial with 59 participants concluded that brushing with Colgate
Total twice daily reduces bleeding on probing adjacent to implant sites in a
three- and six-month period with proven results of reducing plaque bacteria
to help prevent peri-implant disease.
Secondly, products should not irritate the permucosal seal,9 or corrode and/or
etch the titanium.10-11 A high fluoride concentrate of > 3.0 sodium fluoride,
combined with a low PH, will remove the oxide layer on implants and can
make the titanium surface anti-corrosive. Once this layer is removed, the
implant is prone to corrosion. Stannous fluoride can cause etching, roughness
on implants, and their esthetic restorations.
etch the titanium.10-11 A high fluoride concentrate of > 3.0 sodium fluoride,
combined with a low PH, will remove the oxide layer on implants and can
make the titanium surface anti-corrosive. Once this layer is removed, the
implant is prone to corrosion. Stannous fluoride can cause etching, roughness
on implants, and their esthetic restorations.
| Figures 3a, b, c: Interproximal brushes. Courtesy of Hager Worldwide |
What toothbrushes and interdental products are best to use with implants?
Several studies have been conducted regarding what type of toothbrush is most
effective for implants. The results show no significant difference between sonic,
electric, or manual toothbrushes. The main focus needs to be on adaptation to
the prosthesis and the patient's dexterity. Instruct the patient to brush the
implant(s) twice daily to remove bacterial plaque with a low-abrasive dentifrice.
A soft toothbrush should be used ; options include a manual brush, electric, or
sonic brush (examples include Oral-B Triumph, Sonicare, and Waterpik Sensonic
Plus), Sulcabrush, or end-tuft brush.
effective for implants. The results show no significant difference between sonic,
electric, or manual toothbrushes. The main focus needs to be on adaptation to
the prosthesis and the patient's dexterity. Instruct the patient to brush the
implant(s) twice daily to remove bacterial plaque with a low-abrasive dentifrice.
A soft toothbrush should be used ; options include a manual brush, electric, or
sonic brush (examples include Oral-B Triumph, Sonicare, and Waterpik Sensonic
Plus), Sulcabrush, or end-tuft brush.
| Figures 4a, b: Examples of implant floss. Courtesy of Hager Worldwide and Sunstar Americas |
Nylon coated interdental brushes/ proxabrushes are also an excellent
alternative to clean especially tight and hard-to-reach areas around implants
and prostheses. Nylon only interdental brushes (no metal wire) are necessary
to prevent scratching the implant or prosthesis. The interproximal brushes
such as I-Prox P or I-Prox Plus work extremely well and can be dipped in
non-alcohol antimicrobial rinse or gel. It is extremely important to brush
under, around, and in the peri-implant crevice circumferentially
alternative to clean especially tight and hard-to-reach areas around implants
and prostheses. Nylon only interdental brushes (no metal wire) are necessary
to prevent scratching the implant or prosthesis. The interproximal brushes
such as I-Prox P or I-Prox Plus work extremely well and can be dipped in
non-alcohol antimicrobial rinse or gel. It is extremely important to brush
under, around, and in the peri-implant crevice circumferentially
Floss
There are many types of floss on the market, and generally it is highly
recommended to use unwaxed tape or implant-specific floss in order to protect
the tissue surrounding the implant. Alternatively for a bar-retained prostheses,
full fixed retained prostheses, or wider interproximal spaces, a floss threader or
a specialized floss that has a built-in threader is necessary.
recommended to use unwaxed tape or implant-specific floss in order to protect
the tissue surrounding the implant. Alternatively for a bar-retained prostheses,
full fixed retained prostheses, or wider interproximal spaces, a floss threader or
a specialized floss that has a built-in threader is necessary.
| Figure 5a: Insert floss on mesial and distal. Courtesy of Dr. Peter Fritz |
To floss the implant, use dental tape and insert the floss in contacts on both
sides of the implant. Wrap in a circle and crisscross in front, switch hands,
and move in a shoe-shine motion into the peri-implant crevice, which is
highly susceptible to inflammation /peri-implant disease due to biofilm.
sides of the implant. Wrap in a circle and crisscross in front, switch hands,
and move in a shoe-shine motion into the peri-implant crevice, which is
highly susceptible to inflammation /peri-implant disease due to biofilm.
In addition, antimicrobial mouth rinses may be recommended, especially
if inflammation is present or if the patient has dexterity problems, and
difficult-to-reach areas. If the patient is prone to inflammation, the use
of an antimicrobial rinse, in conjunction with a rubber tip stimulator,
may be recommended to inactivate bacteria substantive.
if inflammation is present or if the patient has dexterity problems, and
difficult-to-reach areas. If the patient is prone to inflammation, the use
of an antimicrobial rinse, in conjunction with a rubber tip stimulator,
may be recommended to inactivate bacteria substantive.
| Figure 5b: Crisscross floss and move in shoe-shine manner. Courtesy of Dr. Peter Fritz |
Oral irrigators/Water Flossers
It is highly recommended for patients to use oral irrigators for the
reduction of plaque/biofilm, inflammation, and hard-to-reach emergence
profiles around implants13,14 .Instruct the patient to use
a nonmetal tip one to two times daily, and, if inflammation is present, add
a diluted non-alcohol antimicrobial rinse (chlorine dioxide or chlorhexidine
gluconate).
reduction of plaque/biofilm, inflammation, and hard-to-reach emergence
profiles around implants13,14 .Instruct the patient to use
a nonmetal tip one to two times daily, and, if inflammation is present, add
a diluted non-alcohol antimicrobial rinse (chlorine dioxide or chlorhexidine
gluconate).
Studies using oral irrigators with implants for oral hygiene reveal that
Waterpik Water Flosser is the only oral irrigator to date to be proven safe
and effective with dental implants. A study was conducted to compare
rinsing with 0.12% CHX to using a Waterpik oral irrigator with 0.06% CHX.
The irrigation group using the soft rubber tip (PikPocket Tip, )
at lower pressure was 87% more effective in reducing bleeding and three
times more effective in reducing gingivitis than the rinsing group.
Waterpik Water Flosser is the only oral irrigator to date to be proven safe
and effective with dental implants. A study was conducted to compare
rinsing with 0.12% CHX to using a Waterpik oral irrigator with 0.06% CHX.
The irrigation group using the soft rubber tip (PikPocket Tip, )
at lower pressure was 87% more effective in reducing bleeding and three
times more effective in reducing gingivitis than the rinsing group.
Another study of oral irrigation and floss revealed that the Waterpik Water
Flosser with the standard tip with three bristle filaments (Plaque Seeker Tip,
see opening page) used at medium pressure around implants was 81% more
effective in bleeding reduction compared to 33% using floss.16 These
specialized tips are very effective for implants and to deliver anti-microbial
rinse around difficult-to-reach prostheses (All-on-4, full-fixed prosthesis,
for example) in a prevention of peri-implant disease.
Flosser with the standard tip with three bristle filaments (Plaque Seeker Tip,
see opening page) used at medium pressure around implants was 81% more
effective in bleeding reduction compared to 33% using floss.16 These
specialized tips are very effective for implants and to deliver anti-microbial
rinse around difficult-to-reach prostheses (All-on-4, full-fixed prosthesis,
for example) in a prevention of peri-implant disease.
| Figures 6a, b, c: From left to right, Waterpik Ultra Water Flosser, Waterpik PikPocket Tip, and Waterpik Traveler Water Flosser |
Water irrigation in conjunction with diluted non-antimicrobial rinse has proven
to be extremely helpful for full-fixed and removable prostheses to remove daily
biofilm and prevent inflammation if used on a daily basis. Waterpik makes a
compact Traveler Water Flosser unit, which is my personal favorite to
recommend ensuring patients continue their home-care routine at home and
away .
to be extremely helpful for full-fixed and removable prostheses to remove daily
biofilm and prevent inflammation if used on a daily basis. Waterpik makes a
compact Traveler Water Flosser unit, which is my personal favorite to
recommend ensuring patients continue their home-care routine at home and
away .
Stimulators
Stimulators are coming back into vogue with implants and regenerative
procedures. Remember healthy keratinized tissue is the key to a healthy
permucosal seal surrounding the implant. Stimulators are the ticket to
achieve this, particularly in full-fixed, supra-structure implants, as well as
implants that retain over-dentures (bar-retained implants). Examples of
stimulators are rubber tip stimulators producted by multiple manufacturers
and Soft Picks by Sunstar Americas .
procedures. Remember healthy keratinized tissue is the key to a healthy
permucosal seal surrounding the implant. Stimulators are the ticket to
achieve this, particularly in full-fixed, supra-structure implants, as well as
implants that retain over-dentures (bar-retained implants). Examples of
stimulators are rubber tip stimulators producted by multiple manufacturers
and Soft Picks by Sunstar Americas .
| Figures 7a, b: Examples of stimulators. Courtesy of Dr. John Remien & Sunstar Americas |
Instruct the patient to place the tip of the rubber-tip stimulator so it lays flat
against the gum tissue, not poking in the tissue, with pressure roll to massage
and stimulate the tissue. The tissue will blanch or change to a lighter color
when the correct pressure is applied.
against the gum tissue, not poking in the tissue, with pressure roll to massage
and stimulate the tissue. The tissue will blanch or change to a lighter color
when the correct pressure is applied.
A generalized home-care routine for implants is listed in Table 2 to be
modified to individualize the patient's home-care routine. For an All-on-4
full-fixed case, add the use of a water irrigator unit twice daily with a
non-alcohol antimicrobial mouth rinse in 1:10 dilution to the home-care
guidelines.
modified to individualize the patient's home-care routine. For an All-on-4
full-fixed case, add the use of a water irrigator unit twice daily with a
non-alcohol antimicrobial mouth rinse in 1:10 dilution to the home-care
guidelines.
For removable prosthesis, the patient should use the guidelines in Table 3.
Note that a specific denture cleaner may be recommended for the overdenture.
Plaque and bacteria can also accumulate on the inside of the overdenture,
causing wear to the attachments and oral–systemic health complications
for the patient. Educate the patient on how to do a visual check for attachments
(O-rings, locator caps, and clips) and the importance of these attachments for
retention. If attachments are worn or missing they will need to be replaced.
O-rings and locator caps should be replaced once a year and clips as needed.
Note that a specific denture cleaner may be recommended for the overdenture.
Plaque and bacteria can also accumulate on the inside of the overdenture,
causing wear to the attachments and oral–systemic health complications
for the patient. Educate the patient on how to do a visual check for attachments
(O-rings, locator caps, and clips) and the importance of these attachments for
retention. If attachments are worn or missing they will need to be replaced.
O-rings and locator caps should be replaced once a year and clips as needed.
Hygiene tip: Note the color and attachment type (O-ring, locator or clip) and
record in the patient's chart .
record in the patient's chart .
| Figure 8: Note the color and attachment. Courtesy of Salvin Dental Specialties |
For implants with peri-implant disease, mucositis, and/or implantitis, follow
the home-care guidelines, but add antimicrobial therapy. Use Soft Picks,
interdental, end-tuft or Sulcabrushes dipped in non-alcohol antimicrobial
rinse or CHX gel (compounded by compound pharmacies). "Soak" or apply
the antimicrobial to the infected area twice daily and continue with this
protocol until three to six week re-evaluation.
the home-care guidelines, but add antimicrobial therapy. Use Soft Picks,
interdental, end-tuft or Sulcabrushes dipped in non-alcohol antimicrobial
rinse or CHX gel (compounded by compound pharmacies). "Soak" or apply
the antimicrobial to the infected area twice daily and continue with this
protocol until three to six week re-evaluation.
This article gives the latest home-care products available currently;
however, the technology and implantology is constantly changing. Research
and evaluate home-care products that are safe with clinical research done
on implants. Patients rely on their dental professionals for recommendations
on what products to use and to present them with a safe daily home-care
routine.
however, the technology and implantology is constantly changing. Research
and evaluate home-care products that are safe with clinical research done
on implants. Patients rely on their dental professionals for recommendations
on what products to use and to present them with a safe daily home-care
routine.
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