WE EXPLAIN WHAT THE EVIDENCE SAYS
ABOUT THE PROPER ARMAMENTARIUM
FOR MAINTAINING IMPLANT HEALTH.
By Linh Nakamura, RDH, BS, and
Dianne L. Sefo, RDH, BA
Implant therapy has become a routine treatment
for tooth loss due to its high success rates and
positive effect on patient quality of life. Implant failure caused by
infection surrounding soft or hard tissue, however, can occur. Periimplant
mucositis—inflammation of the soft tissue surrounding an
implant with no resultant bone loss—is reversible with excellent oral
hygiene and regular, professional cleaning of the implant surface and
periodontal sulcus. Peri-implantitis, on the other hand, is characterized
by soft tissue inflammation in addition to bone loss around the implant.1
Current evidence shows that peri-implant mucositis occurs in about
50% of implants placed within 9 years to 14 years,2 while peri-implantitis
occurs in 12% to 47% of implants 5 years after placement.3
The inflammatory response due to the presence of bacterial
biofilm in peri-implant tissue is comparable to periodontal tissues
that develop gingivitis and periodontitis. Therefore, treatment and
prevention of peri-implant mucositis and peri-implantitis are similar
to that of gingivitis and periodontitis. In essence, the removal of
bacterial biofilm and calculus is an essential principle in maintaining
the long-term success of implants.4
Instruments for cleaning dental implants should effectively remove
deposits and cause minimal damage. A variety of instruments have
been proposed and reviewed for the proper maintenance of dental
implants. However, mechanical procedures to clean the dental
implant may negatively affect its biocompatibility by altering the
titanium surface. Meschenmoser et al used scanning electron
microscopy (SEM) to evaluate implant surfaces after instrumentation
with a stainless steel curet, plastic curet, pure titanium
curet, air abrasive polishing system, and ultrasonic
scaler.5 The SEM revealed surface alterations for all instruments
and systems except the plastic curet, which did not
roughen the surface at all. The titanium curet and the air
abrasive system registered only minor effects. These surface
defects have an unpredictable peri-implant tissue reaction,
so the titanium curet and air-powder polisher are recommended
with restrictions. The stainless steel curet and ultrasonic
scaler using a traditional metal insert/tip are not
suitable for cleaning dental implants5,6 because they roughen
the implant surface, which may change the response of the
surrounding periodontal tissues, increasing biofilm retention
and making it more difficult to remove.7
Scaling procedures with curets affect the cell adherence to the
implant surface.8 The SEM demonstrated that both stainless steel
and titanium-alloy curets had fewer attached cells, with the surfaces
instrumented by the stainless steel curet showing the
greatest reduction in cell attachment.5 This may be due to the
possible chemical alteration produced by stainless steel that
may result in changes to the oxide layer, alteration, or contamination
to the implant surface, causing an increase in corrosion.
8,9 These results are indicative of the biocompatibility of
the titanium curet instruments.
Although Teflon-coated sonic and ultrasonic scalers, plastic curets, and
air powder systems cause minimal damage to the implant surface, material
residues have been found on rough surface implants.10,11 Deposits left
on the surface may affect the tissue healing process, which can lead to
the development of peri-implant mucositis or peri-implantitis.10
The ability to mechanically remove residual cement and calculus
deposits is a consideration when choosing an implant scaler. Wilson
found excess dental cement associated with signs of peri-implant disease
in 81% of the cases evaluated.12 Clinical and endoscopic signs of
peri-implant disease were absent in 74% of the test implants after the
removal of excess cement was completed.12 Calculus deposits on
implants are usually softer than on natural teeth and are generally
supragingival rather than subgingival, which allows for easier
removal.13 Mengel et al evaluated various instruments to determine
the quantity of substance removal.6 The results showed that an ultrasonic
scaler, sonic scaler with universal tips, and stainless steel Gracey
curet left pronounced roughness on the titanium surface, but removed
a considerable amount of deposits. The titanium curet and the sonic
scaler left almost no alterations to the surface, but removed little of
the deposits. The rubber cup, plastic curet, and air polishing system
left the implant surfaces unchanged.6
With a wide variety of implant scalers available, dental hygienists
need to select the proper instrument for specific implant surfaces,
such as pure titanium, titanium alloy, titanium plasma spray, or
hydroxyapatite-coated. Many studies have investigated the effects of
hand scaling instruments on implant surfaces. Louropoulou et al
found that nonmetal instruments cause minimal or no damage to
both smooth and rough titanium surfaces, while metal instruments
create the most damage to smooth surfaces.14 However, plastic instruments
and inserts/tips may not be able to effectively removing calculus
or leftover cement.11,15 Additionally, they may leave behind plastic
particles on the implant surface.11,15
Before choosing an instrument, dental hygienists should know
the name, type, and company that manufactured the implant. A
visual examination or tactile sensation is not sufficient to determine
what type of surface an implant is made from. As such, dental
hygienists are responsible for inquiring about the texture of the
implant prior to treatment if the implant is exposed above the bone
level due to bone loss. Clinicians should also refer to radiographs to
determine whether the implant surface is within reach of the instrument
or if it can only reach the abutment surface. Comparing radiographs
at the time of implant placement with current radiographs
is also helpful in determining if there is a change in bone level and
Prior to selecting an instrument, dental hygienists must assess the
health of the periodontium in order to identify the necessary instrument for the maintenance of the implant. Table 1 provides
a five-step assessment plan for comprehensive implant maintenance—
from the visual examination to monitoring bone levels.16
The use of the dental endoscope can be helpful in the subgingival
assessment of dental implants and surrounding peri-implant tissue.
Chemotherapeutic agents can also be considered to aid in the disruption
of biofilm that contaminate the exposed surface of titanium
implants.17 Studies have shown conflicting results with the use of
chemotherapeutic agents so the proper course of treatment should
be based on the individual needs of the patient.18 Hand instrumentation
is still needed for complete removal of the biofilm, calculus,
and residual cementum. When peri-implantitis is present, the use of
Er:YAG and CO2 lasers may be indicated in decontamination treatment.
19 Although beyond the scope of this article, the use of lasers
in implant care shows promise, but more research is needed to determine
the long-term results.
Thorough assessment techniques, use of cutting-edge technology, and
continuing education are all important parts of effective implant maintenance.
However, maintenance programs should be customized on a caseby-
case basis due to the lack of data defining the precise recare intervals
and instrumentation methods for proper maintenance of dental
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From Dimensions of Dental Hygiene. June 2013; 11(6): 16–18.