Quality Resource Guide l Roles of the Hygienist and Dental Assistant in Dental Implant Maintenance 1st Edition 3 www.metdental.com of the implant threads and the bone. 15,16 Occlusion should be evaluated at each recall and adjusted as necessary. Occlusal tape and shim stock aid in identifying occlusal high spots where occlusal adjustment may be needed. All of these varying risk factors should be considered when treating patients with dental implants (Table 1). In-Office Dental Implant Maintenance Dental implant maintenance should include: • Reviewing risk factors • Gathering assessments • Providing treatment • Providing patient education Dental implants should be monitored during regular periodontal assessments at recall visits. Monitoring should include probing, noting bleeding or suppuration, monitoring mobility, and taking appropriate images (Table 2). Probing dental implants was not recommended in the past, but recent literature suggests that regular probing should be included in implant maintenance. 17 Initial probing after implant placement should be done three months after the abutment is placed to allow for proper healing. 18 The clinician should look for changes in probing depths instead of the actual depth of each site. Changes in probing depths may indicate peri- implant disease. Probing should be done with light pressure, and a metal or plastic probe may be used to record probing depths. As with other periodontal diseases, bleeding and suppuration are reliable indicators of inflammation and disease and should be documented. If bleeding, suppuration, or mobility are present around a dental implant, it may be failing. Most often, the patient will not report any pain with failing implants. Mobility is the best indicator of dental implant failure 19,20 and may mean the implant is not osseointegrated into the bone. Mobility is assessed similarly to how it is accomplished on a natural tooth. Two plastic-handled instruments are used to grasp the implant restoration, and light force is applied in facial and lingual directions. Mobility may also be because of a loose abutment or prosthesis. This type of mobility would not indicate peri-implant disease. A dentist should evaluate the mobility of an implant or prosthesis. Dental radiographic images can determine bone loss and the implant’s health. Radiographs should be taken yearly on dental implants and more often in areas where periodontal breakdown has been documented at previous visits. Radiographs may also be taken after the crown is cemented to identify any areas of residual cement. Bone remodeling occurs during the first year after the final prosthesis, but there should be less than 0.2mm of bone loss each year. 21 A failing implant may show vertical destruction of crestal bone around the implant or wedge-shaped defects along the implant 3 (Figure 2). In addition to assessment data collection, clinicians should provide treatment at the recall maintenance visit. A three-month maintenance interval is recommended for the first year after implant restoration. After the first year, maintenance intervals should be individualized based on the patient’s needs. Removing residual cement, calculus, and biofilm deposits should be part of a maintenance visit. Philosophies on types of instruments used for debridement have changed with the increasing evidence. The American College of Prostho- dontists currently recommends that implants be debrided with “like-metal” instruments to avoid leaving any metal residue behind. 21 Most implants are titanium, so titanium scalers would be the most effective and safe to use in scaling. Traditional instruments may be used around the crown, but these instruments should not be used on the implant. Traditional rubber cub polishing is not required for implants and their components. Polishing may be beneficial for rough implant surfaces, but polishing is not required if there are no scratches on the implant or abutment. Air polishing with glycine powder is the preferred method of removing plaque biofilm from around a dental implant, as it is less abrasive than other powders or polish. 22,23 Table 2 - In-Office Implant Maintenance Protocol • Review medical and dental history and assess risk factors for peri-implant disease • Assess probe depths, BOP, mobility and suppuration around dental implants (plastic or metal probe can be used) • Evaluate oral hygiene and plaque control and provide oral hygiene instructions • Evaluate screw-retained implants for plug and evaluate the restoration for wear or damage • Take images of implants once a year (periapical image preferred) to evaluate any changes in bone level • Remove biofilm and calculus as necessary (debride with like-metal instruments, generally titanium scalers) • Evaluate maintenance interval and adjust as indicated • Make referrals as indicated (periodontist, prosthodontist) • Document the above care within the dental record Figure 2 - Failing Implant