Advanced Periodontal Treatment San Diego

Dental implants are now in wide use all over the world and are often considered the standard of care for the replacement of missing teeth. It is estimated that over 5.5 million implants were placed in 2006. According to a recent report by GBI research, over 3 million Americans have dental implants with an expected growth over 500,000 more every year. It is easy to understand why given the numerous benefits of dental implants and success rates over 95%. That said, the prevalence of implant complications such as peri-mucositis or peri-implantitis is on the rise. Data compiled in a report published by AAP in April 2013 found that anywhere from 6-48% of all implants are experiencing these complications. In a busy practice, that number of complications may have serious consequences and prove very bad for business. The good news is that this problem is 100% preventable! All you need to do is establish an implant maintenance protocol to identify risk factors, ensure proper cleaning, and identify problems early on.

It is easy to understand why a lot of clinicians do not have an established protocol. The placement of dental implants became exceedingly common since the early 90s, however, knowledge regarding proper care and maintenance has not. There are no established guidelines regarding instrumentation, record-taking, or frequency. Most doctors and hygienists are confused about if we should even probe them, and with what? As a periodontist, I am often asked these questions and have sought to establish guidelines based on available research to establish an effective preventive implant maintenance program.

Part one of this series discusses the early phases of implant therapy, from the initial consult to the restoration. The second phase of implant therapy is maintenance. It is critical to establish a baseline within a few weeks of restoration for future reference. I like to evaluate all implants about 2 months after restoration. I take baseline radiographs and probing depths, and evaluate the patient’s oral hygiene. This appointment also gives me an opportunity to evaluate the final restoration and ease of access for oral hygiene. By this time, patients have also had some time getting acquainted with their new prosthesis and will often express to me if they are unable to easily floss the area, or are otherwise unhappy or concerned. If needed, I provide them with a new oral hygiene aid such as a proxabrush, and review home care. I now also take time to explain the importance of periodontal maintenance of their implant and schedule them for maintenance in 3 months, regardless of where they are in their current recall regimen. The clock is essentially re-set.

Fast forward 3 months. Now what? Check for signs of inflammation. Visually evaluate the area. Are tissues pink and appear healthy? I recommend gently sweeping a probe through the sulcus, but not to the depth of the sulcus. The peri-implant attachment is very delicate and I try to avoid insult whenever possible. Here we face a common source of confusion and misconceptions. It is completely OK to probe an implant with a metal probe. In fact, the only time I use a plastic one is if the implant is severely overcontoured and a metal probe will not flex enough to pass through the gingiva down to the base of the sulcus. I am not worried about scratching the abutment since numerous studies have shown a small scratch on an abutment is of little concern. However, I do not probe on every maintenance visit the same way I do around teeth. It is important not to probe with too much force, and risk violating the delicate gingival attachment, inducing peri-implant inflammation. If there are no other signs of a problem (the patient is asymptomatic, gingival tissues appear pink, and there is no bone loss), then I simply sweep the probe through the sulcus. If there is any bleeding or other exudate then an accurate probing depth is required, otherwise proceed with the prophylaxis as usual.

Now comes the million-dollar question: with what do you clean the implant? I have spoken with numerous hygienists about this and some confess that they are so confused they barely even touch it. There are several instruments available that claim to be ideal for cleaning implants, but some of them aren’t even effective enough to remove biofilm. Luckily, a recent article by Schmage, et al. shines some much needed light on the topic. Researchers compared the cleaning effectiveness (% remaining biofilm) of a manual plastic curette, manual carbon fiber-reinforced plastic curette (CFRP), sonic-driven prophylaxis brush without prophy paste (Sonic-flex clean), rubber cup with prophy paste, sonic-driven PEEK plastic tip (polyether ether ketone; Sonic-flex clean), ultrasonic-driven PEEK plastic tip (Piezon Master 400), and air polishing with glycine powder (Cavitron Prophy Jet). Both smooth polished surface and roughened surface acid-etched titanium disks where cultivated with Strep. mutans for 3 days to establish a biofilm. Each cleaning method was performed according to manufacturers recommendations for 5 minutes. Researchers found that only the sonic and ultrasonic PEEK plastic tips as well as air polishing sufficiently removed biofilm (<4% remaining). Furthermore, the rubber cup, plastic and CFRP curettes had significantly lower cleaning effectiveness than the other methods. All methods resulted in similar surface damage (scratching), and the rubber were not preferable due to residual rubber particles found left on the titanium disks.

While highly insightful, one shortcoming of this article was the limited number of products tested. One particular product I prefer for the removal of cement or hard deposits are the Wingrove titanium scalers. I attended a lecture by Dr. Wingrove a few years ago and found her argument for the development and use of these scalers highly convincing. Ms. Wingrove argued that in addition to cleaning effectiveness and limited surface damage, we should also be concerned about residual particles remaining in the sulcus. She shared years of research that concluded that titanium was the ideal material for implant maintenance since it left the least debris. There are also plastic covers for ultrasonic tips, carbon composite ultrasonic attachments for piezoelectric handpieces, and many alternative instruments on the market.  Future research is still needed to determine what to guide us in our clinical decision-making on this subject. For now, I prefer to use an ultrasonic tip with a PEEK plastic tip. Careful air polishing with glycine powder or gentle hand scaling with titanium scalers is equally efficacious. The use of lasers to clean implant surfaces has not yet been thoroughly researched but they do not appear to damage the implant surface. Cleaning effectiveness or damage to surrounding gingival tissues has not been sufficiently evaluated.

Finally, I recommend 3-month recall for all implant patients for the first 2 years with yearly periapical Xrays, and bitewing for posteriors (making sure the crestal bone is fully visible-if not take a vertical bitewing). This is based on the fact that early implant complications often occur in the first 2 years. If the patient does not have a history of periodontal disease, is systematically healthy, and has good home care, they are placed on a 6-month recall, with at least one of those yearly visits in my office. If bone loss, bleeding, exudate, or any other sign of inflammation occurs, the patient is referred back to my office for treatment. Management of implant complications will be addressed in the final article of this 3-part series.

To conclude, it is imperative that if there are patients with dental implants in our office, we need to establish evidence-based guidelines to prevent inflammation-based implant complications. Hopefully, more research will emerge soon to better guide us in our clinical decision-making.

Carbon composite ultrasonic tips

Cavitron with plastic implant tip

Sonicflex ultrasonic with PEEK plastic tip

Titanium Wingrove scalers

¹ Albrektsson, Chen, Cochran, Bruyn, Jemt, Koka, Nevins, Sennerby, Simion, Taylor, Wennerberg; Int J Periodontics Restorative Dent 2013;33:9-11
2 Schmage, Kahili, Nargiz, Scorziello, Platzer, & Pfeiffer.  Cleaning effectiveness of implant prophylaxis instruments.  Int J Oral Maxillofac Implants 2014;29:331-337

Dental implants are becoming increasingly common and scientific meta-analyses have demonstrated 97-99% long term success rates. However, there are some basic principles and guidelines clinicians should follow to achieve high predictability and long term stability. In addition to appropriate medical screening of patients, treatment planning, and knowledge of implant-related surgical and restorative principles, there are a few additional steps we can follow as healthcare providers to help achieve predictable and successful outcomes with dental implants. In my office, we have a written implant protocol which is followed from initial consultation through restoration and into periodontal peri-implant maintenance. I share our protocol with you because we have found it to improve patient case acceptance, understanding of treatment timelines, compliance with post-operative instructions and multiple appointments, predictable restorative outcomes, healthy peri-implant tissues, and stable long term results.

Of course, protocols will vary depending on whether your office provides the surgical and/or restorative portion of treatment as well as the prescribed surgical and restorative timeline, but the main components will likely include the following:

1. Implant Consultation & Pre-surgical Planning
2. Surgical Phase & Post-surgical Follow Up
3. Restorative Phase
4. Periodontal Peri-implant Maintenance

Implant Consultation & Pre-surgical Planning

Our implant consultation begins with collecting all the necessary patient information, required legal notices, HIPAA release, etc. Following the initial patient registration, the patient is escorted to our in-house conebeam CT scanner to obtain a full mouth 3D CBVCT. I highly recommend a full mouth scan for multiple reasons. First, I believe in comprehensive examinations and diagnoses. As an oral healthcare provider, I am responsible for all structures between the left and right buccal mucosa, oral labial mucosa to oral pharynx, and floor of the tongue to the palatal gingiva. I perform an oral cancer screening, full mouth periodontal probing, and require full mouth radiographs for all new patients, regardless of the chief complaint or reason for referral. The full mouth radiographs are required for a comprehensive diagnoses and I satisfy this requirement with any of the following: Panoramic xray, FMX, or full mouth CBVCT. I can’t tell you how many asymptomatic periapical lesions or severe periodontal bone loss I have seen on CBVCTs which were not otherwise detectable, but that’s another conversation for another time.

Following the scan, the patient is seated in an treatment room, medical history and dental history reviewed, and clinical exam is performed. My exams always include full mouth periodontal screening and intraoral photographs with my extraoral camera. The periodontal screening is critical for many reasons; identifying the presence of periodontal disease as well as the patient’s ability to perform proper oral hygiene. If either of these components are inadequate, these topics must be addressed with the patient prior to initiating implant treatment. Extraoral photos are used not only for documentation purposes, but also to discuss any restorative limitations or considerations with the patient. For example, I often see spacing or crowding issues, inadequate keratinized gingiva, uneven gingival margins and asymmetries, or recession on adjacent teeth. I use good extraoral photos to explain these esthetic or restorative limitations prior to beginning treatment, thus establishing appropriate patient expectations during the consultation.

I take time to review clinical findings, diagnoses, recommended treatment & treatment options (including a brief explanation of the less acceptable alternatives), expected post-operative recovery, overall treatment timeline, and importance of peri-implant periodontal maintenance. For complex cases, a second appointment may be required to complete the consultation. As a periodontist, I also make a point to explain what roles the restorative dentist and myself will play in the process. My office manager then takes over and presents related fees and estimated insurance coverage, if any. She is instructed to clearly explain how dental implants and related procedures are the most advanced dental treatment and several insurance plans have specific limitations and requirements in the ‘fine print’. She further explains that it is not uncommon to have little or no insurance benefits to help pay for the cost of treatment. (Of course how you handle this in your office is up to you; this is just what we do in my office to prepare our patients financially.) We also make a point to explain the distinction between surgical costs and restorative costs, so the patient has all financial information prior to beginning treatment.

Surgical Phase and Post-Surgical Follow-up

All patients are examined within 2 weeks of any surgery. Follow-ups then continue periodically (4-6 weeks post-surgery) until the site is completely healed and patient is asymptomatic. If the treatment plan calls for tooth extraction and healing prior to implant placement, we schedule a “pre-operative” appointment approximately 3 months after tooth extraction to evaluate hard and soft tissue contours, review the implant procedure and answer any questions, collect payment, and schedule for the implant surgery. Coordination with the restorative dentist is also done at this time if needed for surgical guides, etc. Following implant placement, the patient is seen for regular follow up as mentioned previously. Implant treatment plans often call for a waiting period after implant placement, prior to restoration. When the implant is suspected to be ready for loading, the patient is quickly seen for a ‘pre-restorative check’. If an uncovery is needed to remove the cover screw and place a healing abutment, it is done 2 weeks prior the pre-restorative check. During this pre-restorative visit, I evaluate proper gingival healing and soft tissue contours, a periapical radiograph is taken to check for any crestal bone loss and ensure the implant is healed and ready for restoration. This appointment is also a method we use to follow up with our implant patients and insure they follow through with the restorative phase.

Restorative Phase

As a periodontist, I am not involved much with this phase. We simply schedule the patient for a “post-restorative check” 2-3 months after the pre-restorative check. During this appointment, final photographs are taken, baseline probing depths are recorded, occlusion is checked, implant hygiene and home care are reviewed, and a final bitewing radiograph is taken to check for residual cement. The patient is also reminded about the importance of proper maintenance to protect their investment.

Periodontal Peri-implant Maintenance

All implant patients are seen 6 months after implant placement for periodontal maintenance. In some cases it may be recommended for the patient to begin a 3 month periodontal recall, alternating every other visit between my office and the restorative doctor. Other patients may be recommended to return only once a year for the first 5 years for an implant check (limited evaluation) and periodontal maintenance, in addition to the regularly scheduled semi-annual cleanings with their restorative dentist.

This protocol is not a fit for every office and the number of visits may seem excessive, but this is what I have found to work for my office, patients, and referring doctors to achieve excellent patient compliance and predictable outcomes. I hope sharing my protocol can serve as a starting point for you to consider when treatment planning for dental implants. Part 2 of this article will discuss implant maintenance protocols and current thoughts on the diagnosis and management of peri-implant inflammation.