Caring for Patients with Implants in the Hygiene Operatory
Patients no longer have to grin and bear it when it comes to edentulism. These days, there are many options when it comes to replacing dentition, from bridges and dentures to dental implants that are virtually indistinguishable from natural teeth.
Although implants may look like the real deal, the care and upkeep of dental implants—and the patients who have them—can differ greatly from that of natural dentition. In terms of ensuring the longevity of an implant, this is critical to remember.
“When an implant is placed, we tell patients, ‘It functions like a natural tooth. It feels like a natural tooth. You can floss it like a natural tooth,’” says Katrina Sanders, RDH, BSDH, M.Ed, RF. “And I think after enough times of saying that, we begin to believe that we can instruct our patients to care for dental implants just like they would their natural teeth. The difference is that if you do this, dental implant failure can occur, and I think people forget this.”
So what does it take for hygienists and patients alike to properly care for dental implants? Understanding how implants behave, knowing the risk factors for periimplantitis, and the ability to identify red flags for possible complications are critical.
“There is a science caring for implants, and you have to know the steps of assessment and…how to do implant maintenance,” says Susan Wingrove, RDH, BS, author of Peri-Implant Therapy for the Dental Hygienist. “Research is constantly being done. For instance, we now have new ceramic implants, and we have to know how to maintain and home care for those as well. You have to know how to assess the situation.”
Assessing Implants
A hygienist can’t provide proper care for an implant until they know what condition it is in. This is where a thorough assessment comes in.
“Patients have invested in their oral health with dental implants,” says Theresa Biernat, RDH, BS, MBA, a project manager at HuFriedyGroup. “The maintenance and support of their investment is critical, and clinical implant assessment is the cornerstone of sustained success. In performing an intraoral implant assessment, clinicians must take a multifactorial approach.”
To ensure this approach is followed—and that hygienists don’t skip any critical steps or miss any important warning signs—Wingrove created a 5-step assessment.1
- Examine the soft tissue visually
The first step of the 5-step assessment is the same as what you would do with natural teeth: Look at the tissues around the implant and examine it for signs of inflammation. Inflammation is a clear indicator there could be a problem. - Check for signs of infection
Probing and palpating are good ways to identify any potential problem areas. Wingrove recommends palpating the implant to see if any exudate or bleeding happens. Palpate the area by putting 1 finger on each side (buccal and lingual) of the implant and milking up toward the crown (or, on the upper, press down toward the crown). “If there’s bleeding around an implant, you have to get to the bottom of it as soon as possible,” says Wingrove. “If that inflammation cascade continues, you’ll have a chance of losing bone.” - Look for residue
Residue can signal the death knell for implants. Residue (such as that from calculus, instrument shavings, or cement) can stick on the implant and trigger an inflammatory response. To identify any residue, the clinician needs to properly and carefully floss the implant.
Wingrove emphasizes that flossing the crown correctly takes several steps. “It’s mesial, distal, cross in front, then you have to shoeshine so that it meets where the abutment meets the implant—that’s the sweet spot,” she says. “Go back and forth a few times, then remove it out of the mesial and the distal—you don’t want to pull it through.”
Proper flossing is exceptionally important because, if done incorrectly, the floss can inadvertently leave behind more residue instead of removing it. It is now only recommended for single implants with no thread exposure and by clinicians as an assessment tool.
“You have to be really careful about what is exposed on the implant,” Sanders says. “If there is exposure of the threads of the implant, floss can shred. Shredded floss can essentially create a bacteria trap, creating nodules for additional bacteria to form in the area.” - Assess occlusion and mobility
Although natural teeth have a little mobility and flexibility, implants should not. Because implants are rooted into the bone and aren’t supported by ligaments like natural teeth, there shouldn’t be any give.
“Implants are like putting it in cement,” says Wingrove. “It shouldn’t move. With no ligament attachments, it should be solid. If you’ve got movement, the doctor needs to assess for multiple causes, and a radiograph [should be] taken.” - Take a picture
Because the implant is screwed into bone, bone loss could potentially trigger implant failure. To assess bone condition, radiographs should be taken annually. Vertical bitewings or periapical radiographs are typically the most accurate. These radiographs should be compared with the baseline radiographs from 1-year postrestoration.
“A radiograph will tell you if the implant is healthy or not,” says Wingrove. “Bone loss around the implant is the assessment for the health of the implant.”
Using the Right Tools
Because implants aren’t natural teeth, they shouldn’t be treated with the same tools. Having an implant changes which products should be used (both in the operatory and at home) and hygienists and patients need to adjust accordingly. According to the American College of Physicians Clinical Practice Guidelines, instruments should only be used that are “compatible with the type and material of the implants, abutments, and restorations.”2
“We’re understanding a lot more about how implants need to be maintained and cleaned differently than our traditional teeth,” says Debbie Durako, director of StellaLife Inc. “That’s very important to remember to aid in the prevention of periimplantitis.”
Wingrove agrees. “Because it’s a medical device, it’s not the same as a natural tooth,” she says. “If people have even 1 implant in their mouth, it changes what they can do, what products they can use, and what instruments hygienists can use for the maintenance visit.”
Identifying the proper instruments is the first step. Although stainless steel instruments might be the go-to for natural teeth, they shouldn’t be used on implants. Instead, hygienists should turn to titanium scalers.
But it’s not only stainless-steel instruments that should be avoided. Although many people were taught in dental school that plastic scalers should be used on implants because they are softer and less likely to scratch the implant, they may not be getting the job done properly and could be causing more harm than good. Sanders references periimplantitis cases she’s seen where curls of plastic were found among the threads of the implants once the doctor opened the flap.
“Clearly a hygienist was once trying to clean that area, and pieces of plastic started to peel off and were then embedded into the threaded area,” she says. “Of course, this then created other niches for bacteria to be able to form, and it’s a difficult thing for the tissue to heal. The good news is that there are a lot of other amazing tools out there.”
Some of the tools Sanders turns to are implant scalers that have a change in the hardness level without the risk of curling of plastic, as well as PDT Wingrove scalers. “These are just 2 examples of hand instruments that are available that are shaped completely different to allow for efficiency of the subgingival space.”
“You can’t be using your plastics, graphite, or stainless steel that you’ve been using in the past,” Wingrove says. “The concern is you can leave residue behind if you’re using the wrong instrument, because residue stuck on the implant will build up over time, and you could lose the implant if the wrong instruments are used on debriding the implants. You need to have a set of titanium scalers. You need to have the proper tool set.”
In addition to titanium scalers, there are plenty of tools that can be used to provide proper implant care. Technology like subgingival air polishers, powder streaming devices designed to gently remove biofilm without causing damage to implants or associated components. It can also aid in the reduction of inflammation and the prevention of related diseases, such as gingivitis and periodontitis/periimplantitis.
Scalers and other tools aren’t the only risk for implants. Using the wrong clinical products or recommending the wrong home care products can also be problematic. As 1 example, avoiding high fluoride products is critical, as high fluoride with a low pH could possibly remove the oxide layer on a titanium implant. Wingrove recommends only using products with a neutral pH that are safe for both pre- and post-procedural rinses. These products include chlorine dioxide rinses from CloSYS, OraCare, OxyFresh, and StellaLife, which she considers to be the top 4 for pre- and postsurgical procedures, as well as pre-and postmaintenance visits.
“The first step in care is preparing the patient for surgery or maintenance,” Durako says. “You’ve got to do a good job of being able to prepare the tissue and oral microbiome for surgery. That’s where StellaLife comes in with our 3-3-3 program.”
The 3-3-3 program is a combination of 3 all-natural products (an antimicrobial rinse, sublingual spray, and topical gel) used 3 times a day for 3 days prior to implant surgery and implant placement. These products reduce the anaerobic bacteria in the oral cavity and kills Streptococcus mutans and Porphyromonas gingivalis. In conjunction, the tissue is being saturated with anti-inflammatories.
“Once the patient gets prepared for surgery, you’re already in a better position to have a better postoperative outcome,” Durako says. “Patients can use the products for 7 days after, which helps control bacteria (thereby hastening wound healing) and also reduce inflammation.”
Outside the Operatory
Postprocedural rinses are just 1 way that patients can improve their implant home care after they leave the operatory. But patient compliance can be a tricky thing, and hygienists need to find ways to provide effective options that simplify oral care. Although proper monitoring and maintenance are essential to preserving the health of a dental implant, the long-term success of an implant is fundamentally dependent on the dental team’s administration of professional prophylaxis procedures and the efficacy of the patient’s home care.
“How do we teach patients that, [although] they have all these beautiful implants, there is a level of maintenance that has to occur?” Durako says. “[Although] that includes visits to have the implants checked and cleaned, care has to continue at home. If we can make it easy for them, we will see compliance rise. Things like the Philips Sonicare or the Waterpik Sonic-Fusion are brilliant, because it’s a one-stop shop; I don’t have to whip out another tool, I can do it in 1 fell swoop.”
Biofilm research has found that, for optimal oral health, 80% to 85% of biofilm should be removed twice daily.3 The easiest way to accomplish this is to use an electric toothbrush and/or a water flosser. A water flosser becomes even more important as trends shift toward discouraging patients from flossing around implants because of the risk of residue and the resulting complications. Water flossers are also handy when implant threads are exposed, as water flossers create effective lavage to flush out any bacteria that may live within the embedded threads of the dental implant.
“It’s important for us to acknowledge that the tools we send our patients out with are what they are going to maintain their health with for 361 or 363 days out of the year when we aren’t seeing them in recare,” Sanders says. “Water flossers are truly the unsung heroes of keeping a lot of our implant patients in a state of stability. [Most of] our patients that have these dental implants have periodontal disease and are oftentimes experiencing other comorbidity challenges where dexterity and their ability to clean the area could be a challenge. Putting an auto flosser or a water flosser in our patients’ hands helps them to keep the area far cleaner.”
Ultimately, in addition to simplifying home care, patient education is key.
“You can have the most beautiful implant or natural tooth restoration, but if the patient doesn’t know how to care for it at home and doesn’t come back for maintenance, how long is it going to last?” Wingrove says.
Providing the Best Care
A combination of accurate assessment, proper hygiene protocol, good home care, and plentiful patient (and hygienist!) education is the key to implant success. Without any 1 of these facets, patients face higher risks of periimplantitis and other implant complications. Hygienists should stay abreast of the latest research, materials, and tools; without this knowledge, they will be unable to effectively communicate information and instructions to patients.
“Our hygiene teams need support and a lot of education, because we have to maintain implant patients now,” Durako says. “This is not a short-term condition that patients are never going to have to think about again. The investments are large for [patients], so it’s important we help them maintain oral health so they aren’t in a situation where they may have to redo an implant or struggle with wound healing.”
Biernat agrees that hygienist education is critical.
“The field of dental implant maintenance is constantly evolving as new materials, techniques, and protocols are developed,” she says. “Keeping current with evidence-based research and updating treatment protocols as they become available is the best way to ensure cutting-edge optimal treatment.”
Wingrove agrees that implant science is evolving and is releasing an updated version of her 2013 book in 2022 to reflect the latest trends and research. When it comes to implant science, change is good, but it means that both hygienist and patient education are lifelong commitments.
“We have the opportunity to guide our patients through this,” Sanders says. “Just because I’m loading this implant doesn’t mean we’re gone. Just like periodontal disease, after you perform active perio therapy, that patient is in maintenance for life. They’re in remission, we’ve got to keep them there, and dental implants are the same way.”
References
- Wingrove S. Peri-Implant Therapy for the Dental Hygienist: A Clinical Guide to Implant Maintenance & Disease Complications. Wiley-Blackwell; 2013.
- Bidra A, Daubert DM, Garcia LT, et al. Clinical practice guidelines for recall and maintenance of patients with tooth-borne and implant-borne dental restorations. J Prosthodont. 2016;25 Suppl 1:S32-S40. doi:10.1111/jopr.12416
- Jiao Y, Tay FR, Niu LN, Chen JH. Advancing antimicrobial strategies for managing oral biofilm infections. Int J Oral Sci. 2019;11(3):28. doi:10.1038/s41368-019-0062-1
