Are we neglecting it?
One of the key factors for the long-term success of oral implants is the maintenance of healthy tissues around them. A cause-effect relationship between bacterial plaque accumulation and the development of inflammatory changes in the soft tissues surrounding oral implants has been shown. If this condition is left untreated, it may lead to the progressive destruction of the tissues supporting an implant, which may compromise its future and ultimately lead to its failure.
For maintain healthy tissues around oral implants it is important to institute an effective preventive regimen (supportive therapy). An understanding of the reasons why patients have lost their teeth is an important issue. Patients who have lost their teeth as result of atrauma or an accident are usually compliant patients, because they did not expect to lose their teeth. Conversely, patients who have lost their teeth as a result of periodontal disease or neglect are often more challenging.
Since dental implants are highly maintenance intensive, noncompliant patients must be thoroughly educated and retrained before deciding to begin implant therapy. The patient’s understanding of the maintenance requirements I crucial, and these obligations must be made clear to the patient initially and during subsequent appointments
The best implant candidate is a patient who is informed about dental treatment options, has a high level of home care, and has accepted and responded well to past dental care and treatment.
1) PROSTHESIS DESIGN AND MAINTENANCE
The type of restoration over the implant abutments can vary from patient to patient Generally, the fewer the number of prosthetic components involved the easier maintenance will be the design of the prosthesis should allow for access by the patient and clinician to keep the areas free of plaque when designing a bridge it is important to create accessible embrasure and contact spaces interdental hygiene aids (e.g. specially flosses, interdental brushes and end –tuft brushes) should allow ease of access. If a contact is tight of an embrasure space in inadequate, it may be difficult or painful for u patient cleanse with floss if the patient has a retrievable superstructure it should be remote every 18 to 24 months placed in an ultrasonic cleaning solution with the superstructure removed, direct access to the implant abutments in possible. Implants have a highly polished collar that is essential for the prevention of plaque for mation and retention. When scaling around an implant, the scaling pressure applied is important. The tissue cuff around an implant should be tight when healthy, which can create difficulty while scaling,. Because of the delicacy of the peri-mucosal seal, the best method for removing calculus is by using short working strokes with light pressure.
2) INSTRUMENT SELECTION
The maintenance of smooth surface of the titanium without pits and scratches is important to prevent plaque accumulation. Stainless steel and titanium – tipped instruments are detrimental to a smooth titanium surfrace.2 Cavitron and sonic scalers have also been found to gouge titanium.3 A plastic sleeve over a sonic scaler appears not to alter titanium4 and may be used in cases of heavy calculus accumulation. Air polishing systems will blast many scratches into the titanium and should not be used. The most important consideration is selecting calculus and plaque.5 The following are general guidelines for maintenance of implants6;
1. Special instruments are recommended for assessing and debriding implants. Plastic instruments are used most commonly because the plastic material is softer than the implant material
2. Metal instruments (e.g. stainless steel, carbon steel, and ultrasonic instruments) may leave scratches on the surface of the implant. This may promote accumulation of plaque. Surface coating of an implant may be disturbed, thereby reducing the biocompatibility of the implant with the surrounding tissues. 3. Some plastic instruments contain graphite fillers; these types of instruments may be used on the implant superstructure (prosthetic denture or bridge) but should not be used directly on the implant abutment (to avoid scratching of the abutment surface).
4. Wrench – shaped, crescent-shaped, and hoe shaped plastic working ends are useful for the debridement of an implant’s superstructure. Working ends that are similar in design to conventional metal probes, sickle scalers, and curettes are useful for the assessment and debridement of an implant abutment. 5. Calculus is removed easily from implants because there is no interlocking or penetration of the deposit within the implant surface. Light lateral pressure with a plastic scaler or curette is recommended. Care must be taken not to scratch the surface of the implant.
Certain implant scalers can be sharpened. If implant hygiene instrument are sharpened , it is important to use a sharpening stone that has not been used for metallic instruments, since metal from the stone can be embedded into an instrument’s surface. A variety of nonmetallic, plastic, graphite, nylon- coated, or Teflon –coated instruments are abailable and have been proven safe to use on titanium implant surfaces.
Rubber cup polishing with toothpaste, fine prophy paste, commercial implant polishing pastes, and tin oxide have been shown not to alter titanium surfaces.2 Before polishing, calcified deposits should be removed. In addition to a rubber cup, a rubber point or soft unitufted rotary brush may be use
4) SUBGINGIVAL IRRIGATION
Irrigation of the implant sulcus by chemotherapeutic agents may be useful as a long –term maintenance procedure. The irrigation canula should have a nonmetallic, rounded tip with side escape portals. During its use, the canula is not inserted to the base of the implant sulcus, preventing fluid distention into surrounding tissues. Chlorhexidine gluconate is a useful irrigant.7
With the vast number of manual and automatic toothbrush available, patient preferences are the key guides. A soft or extra –soft toothbrush will accomplish plaque and debris removal without traumatizing tissue.
A motorized toothbrush such as the Rotodent may be used with a tapered brush to access the undersurface of connector bars or to aid with interdental cleansing. The sonicare has sonic technology which demonstrates the ability of this toothbrush dental surface similar to implants.
Tufted brushes may also be advantageous in hard –to reach areas of for more site-specific purposes. Tufted brushes are especially useful in posterior lingual regions where a conventional toothbrush might not reach. Heating the plastic handles with hot water of flame may allow the brush to be bent or angled for patient- specific anatomy and needs.
Patient instruction for using floss should be aimed at gentle insertion and motion to avoid trauma to tissue. A threader may need to be used to access bridgework or around connector bars. There are also numerous woven flosses with threaders built in to help access and cleanse larger embrasure spaces and under connector bars.
Yarns and loosely woven floss can also be used, but these should not be considered if there is the possibility of fibers being retained on rough surfaces or around restorations. PostCare (john O. Butler Company, USA) is a braided flossing cord. It is more rigid than conventional floss but easy to use in open areas and places where a floss threader may be too flimsy. The braided flossing cord may also remove denser plaque, debris, and calculus that is not too tenacious.
Proxy-Floss (AIT Dental, USA) is an elastomeric material made up of hundreds of semicircular flanges that bend and flex to remove plaque. And debris or to apply chemotherapeutic agents. The elastomeric nature of this product prevents it from collapsing snagging or shredding
7) Many companies manufacture interdental brushes.
It is important that the bristle are plastic or coated with nylon to prevent scratching of the titanium components. Patients should also be instructed to inspect and change the brush when signs of wear are evident. Common brush designs include straight and cone –shaped. Embrasure size and shape should be considered to prevent brush bending and tissue trauma.
Foam tips (Oral-B) can also be used to apply chemotherapeutic agents interdentally and site specifically.
Proxy – Tip (AIT Dental, USA) is an inter proximal brush and stimulator. It has many soft, flexible, semicircular flanges that remove plaque and facilitate application of antibacterial agents. It acts as an interdental brush and rubber tip in one design
8) ORAL IRRIGATION
Oral irrigation helps remove plaque and debris from around dental implants and their restorations. The patient should be instructed to use the lowest setting possible to avoid undue pressure to the implant tissue cuff. The flow of irrigation should be aimed to pass through contacts and never be directed into tissue. Incorrect use could cause trauma to tissue adaptation around the implant and could cause bacteremia.
9) CHEMOTHERATEUTIC AGENTS
Chlorhexidine gluconate has been shown to be a major asset in reducing plaque in the oral cavity and around dental implants. Long-term use of antimicrobials (e.g. chlorhexi-dine gluconate) may be used with brushes and floss to avoid stain accumulation.
10) POCKET WATCH
Steri -oss markets a product called pocket watch which consists of chemically treated strips, reagent and testing trays. It assesses the presence and quantity of aspartate amino transferace (AST) in gingival crevicular fluid. These strips are inserted in crevice for 30 seconds and then four reagents are used with which the strips interact to assess the presence of the enzyme by comparing the various shades of pink with standard
The rate at which a patient forms plaque and calculus need to be determined and the effectiveness of the recommended home care techniques must be consistently evaluated. The General health of the patient and conditions that may require pharmaceutical therapies. Such as gingival hyperplasia caused by certain cardiovascular medications may compromise a patient’s overall ability to care for implants and their restorations. Potential problems can be detected and usually treated early, easily and successfully if thorough evaluation is performed at each visit. Although which is the most effective plaque control intervention, it is essential to maintain a good oral hygiene around the implants for long-term success.
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4. Baily G, Gardner J, Day M, Kovanda B. Implant surface alterations from a nonmetallic ultrasonic tip. Periodontol Abstracts 1998; 46: 69.
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6. Darby ML. Mosby’s Comprehensive Review of dental hygiene, 5th edition, 2002; 708-710
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