Oral Hygiene Implications for Dental Implants
Linda Teal Mercer, RDH, MPH
Patient education, oral health assessment, and maintenance have traditionally been the responsibility of the dental hygienist. As dental implants become increasingly common among our recall patients, dental implant protocols must be redefined and reevaluated.
Dental implant therapy enjoys a greater than 90% success rate.1,2 Although there tend to be few complications associated with implants (eg, infection, pain, or bleeding),1-3 this restorative option is contraindicated for patients with systemic diseases that reduce immune defenses (eg, HIV/AIDS, uncontrolled diabetes mellitus).1-4 Smoking,1-6 substance abuse,1,2,4 and stress1 have all been identified as factors that heighten the incidence of postoperative complications.As with most dental therapy, a medical clearance from the patient’s physician is required if the patient presents with blood coagulation disturbances, is taking steroids, or has cancer that requires chemotherapy.1,4
Maintaining an Implant-Supported Restoration
Most implant surfaces are fabricated using titanium or hydroxyapatite to facilitate osseointegration. A dental implant has a junctional epithelium (ie, perimucosal seal) that separates the internal tissue from the oral cavity. Once the implant, abutment, and prosthesis have been placed, frequent recalls should be established.1,2,8 During these recall visits, accurate charting and radiographic evaluation are essential, as the clinical appearance of an implant may resemble a typical crown restoring a natural tooth (Table).
The two most common causes for implant failure are plaque accumulation and excessive occlusal forces.1-3 As with natural teeth, areas of edema, erythema, suppuration, and spongy tissue are signs of compromised health. Probing depths should be recorded using a plastic probe and gentle adaptation. Because there are no periodontal ligaments surrounding a dental implant, there can be no mobility associated with a healthy implant.1,2,4,8
Effective plaque control is necessary to maintain a healthy environment. Although deposits will accumulate on the supra- and subgingival surfaces of the dental implant, they are not as tenacious as those found on natural teeth (Figure 1).7 Metallic instruments should never be used on implants, as these surfaces will scratch easily and predispose the site for subsequent complications (Figure 2).1-4,8 Tufted floss or gauze are both effective for removing plaque from around and under prosthesis (Figure 3).1,4 The dental hygienist may also utilize a rubber cup with a non-abrasive paste (Figure 4).3,6,8 When indicated, subgingival irrigation with 0.12% chlorhexidine is safe to use around implants (Figure 5).4,8,11
Radiographic examinations should be included at 6- to 12-month intervals. Marginal bone levels and bone density may be monitored with individual periapicals or vertical bitewings. A healthy implant should experience no more than 0.2 mm of bone loss annually.1 Depending on the type, it can be helpful to remove the prosthesis annually, and coordination among dental hygienists and professionals is key to identifying such instances. This will increase access and assist with the visual evaluation of the tissue. Abutments and screws should to be examined at each recall.1,8
Complex restorations make effective home care challenging. Studies show that powered toothbrushes are a safe and effective way the control plaque in these areas.4,5,8-10 Dental floss, gauze, interproximal brushes and end-tufted toothbrushes are all good adjuncts.3,4 Keeping these recall guidelines and homecare suggestions in mind will ensure quality care is provided for your implant patients.
*Assistant Professor, Department of Dental Hygiene, University of New Haven, West Haven, Connecticut.
- Weinberg, Mea A. Comprehensive Periodontics for the Dental Hygienist. Upper Saddle River, New Jersey: Pearson Education, Inc; 2006.
- Iacono VJ, Committee on Research, Science and Therapy, the American Academy of Periodontology. Dental implants in teriodontal therapy. J Periodontol 2000;71(12):1934-1942.
- Gladwin M, Bagby M. Clinical Aspects of Dental Materials: Theory, Practice, and Cases. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkens; 2004.
- Baig MR, Rajan M. Effects of smoking on the outcome of implant treatment: A literature review. Indian J Dent Res 2007;18(4):190-195.
- Chuang SK, Wei LJ, Douglass CW, Dodson TB. Risk factors for dental implant failure: A strategy for the analysis of clustered failure-time observations. J Dent Res 2002;81(8):572-577.
- Wilkens EM. Clinical Practice of the Dental Hygienist. 9th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2005.
- Nield-Gehrig JS. Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2008.
- Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby; 2007.
- Vandekerckhove B, Quirynen M, Warren PR, et al. The safety and efficacy of a power toothbrush on soft tissues in patients with implant-supported fixed prostheses. Clin Oral Investig 2004;8(4):206-210.
- Costa MR, Marcantonio RA, Cirelli JA. Comparison of manual versus sonic and ultrasonic toothbrushes: A review. Int J Dent Hyg 2007;5(2):75-81.
- Felo A, Shibly O, Ciancio SG, et al. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent 1997;10(2)107-110.
Table 1: Hygiene Protocol Following Implant Placement
Indications of Implant Success
• No mobility
• No pain
• No BOP
• No radiographic evidence of bone loss
• No signs of inflammation
Evaluation at Recall
• Scale and probe with nonmetallic instruments
• Deplaque with gauze or tufted floss
• Selective radiographs
• Selective polish with a rubber cup and nonabrasive agent
• Subgingival irrigation as needed
• If fluoride application is indicated for natural teeth, use only neutral sodium fluoride
Review Home Care
• Brush at least twice daily with an appropriate toothbrush (ie, soft-bristled, power, end-tufted)
• Floss daily
• Employ interproximal brushes
• Rinse with an antimicrobial agent as directed