The hygienist’s role in dental implants
Dental implants are a viable and commonly used treatment option for tooth replacement. We have often heard the terms peri-implantitis and peri-implant mucositis in reference to inflammation or infection around an implant; the difference being the lack of supporting bone in peri-implantitis. There is ample evidence from various studies showing that the frequency of peri-implantitis is in the range of 1-19% (Roos-Jansaker et al, 2003). Implant treatment was introduced comparatively recently and, as a result, we may reasonably expect the number of peri-implantitis cases to increase over the years, particularly as more implants are being placed.
There are different options used in the treatment of peri-implantitis. One is ‘cumulative interceptive supportive therapy’ (CIST). This is where patients with implant probing depths <4mm would receive oral hygiene and debridement with soft scalers, rubber cups and paste. Patients with implant probing depths of 4-5mm would receive similar treatment, in addition to antiseptic therapy of chlorhexidine gel or rinse daily. Where the probing depth is ≥6mm, the patient receives the above mentioned treatment, in addition to tetracycline fibres – which would be used in conjunction with systematic antibiotics for 10 days. Surgery may be considered only after successful elimination of infection. This may include the regenerative approach using barrier membranes or the resective approach using osteoplasty or apically positioned flap (Lang et al, 1997).
One study over a period of five to 10 years between installation and re-examination of the implant showed that episodes of peri-implantitis were successfully treated by CIST. The study examined 64 implants, 15 of which had peri-implantitis; one implant was lost in a patient with diabetes (Rutar et al 2001).
The list of treatment options for peri-implantitis continues as there is no ‘gold standard’ approach. Some options include:
• Use of mechanical debridement alone – using an ultrasonic device or carbon fibre curettes. However this may not be sufficient to decontaminate implant surfaces ≥5mm and exposed implant threads (Kotsovilis et al, 2008)
• Er:YAG laser for non-surgical therapy showed a significant reduction in bleeding on probing, but this was limited to a six-month period – particularly in advanced peri-implant lesions. Further studies are needed to determine whether this outcome can be maintained over the course of time
• Mechanical debridement combined with antiseptic agents – there were improvements in pocket depths but residual defects persisted following therapy, which suggests supplementary treatment may be required
• Both nanocrystaline hydroxapatite and guided bone regeneration showed improvements in clinical parameters considered to be clinically significant.
The review of the various treatment options for peri-implantitis brought preventive care to the forefront. It was observed in one of the studies (Schwartz, 2005) that an adequate level of oral hygiene was not achieved, as there was an increase in the plaque index from baseline to 12 months, implying ineffective oral hygiene measures.
Consequently, the result of the study should be interpreted with caution (Kotsovilis, 2008). Another conclusion drawn suggests that patients with a history of chronic periodontitis may demonstrate a higher incidence of peri-implantitis than patients without a history. Therefore, a history of chronic periodontitis may predispose the development of peri-implantitis.
An increasing number of studies concluded that plaque bacteria have a detrimental effect on the health of peri-implant tissue. Patients need to have good oral hygiene before implants are placed, as well as the understanding that implants need maintenance in very much the same way as teeth do.
The hygienist role starts with preparing the patients for implants, followed by supportive therapy during and after implant placement. Patients with periodontal disease need to achieve periodontal health before implants are placed. Periodontal pathogens from residual pockets may be transmitted to the peri-implant environment. Microbes in the peri-implant pocket are similar to those encountered in residual periodontal pockets within the same oral cavity (Rutar et al, 2001).
In a study observing the nine- to 14-year follow-up of implant treatment (part one), a factor that showed significant association in implant loss was a previous history of periodontal disease (Roos-Jansaker et al, 2006). It was noted in part two of this study that the patients had low yearly visits to the hygienist, which indicated the absence of a structured supportive treatment programme. As these patients did not have a uniform supportive periodontal treatment programme, the risk of developing peri-implantitis was increased. Therefore, it is most likely that supportive care will influence the outcome of the implant treatment.
Another finding of the follow-up of implant treatment suggests bone loss of more than 3mm and pocket depth >6mm were common around implants after this period in function. We need to be aware that peri-implant infections may occur among more than half of patients after 10 years if systematic supportive therapy is not provided (Roos-Jansaker et al, 2006).
Smokers may have a lower implant survival rate. Consequently, smoking cessation should be a part of the initial therapy before implants are placed. It is well established that smoking, diabetes and some systematic conditions increase the risk of periodontal disease. There is some debate on the risk to osseodisintegration, but increasing evidence points to the detrimental effect of smoking on peri-implant tissue (Rutar et al, 2001).
Supportive therapy has a role to play in maintaining the integrity of implants. Patients need to be instructed on how to maintain proper oral hygiene around implants and the remaining teeth. Patients who smoke and those with a history of periodontal disease need to be closely monitored. Before the initial treatment, patients need to be aware of the risk factors associated with the development of peri-implantitis.
Patients will need a regular, structured, supportive maintenance programme, not only for the long term maintenance of implants but also to aid in the early diagnosis of peri-implant infections. Implant loss can be kept to a minimum if peri-implant lesions are detected at an early stage and the disease is intercepted by appropriate means. In addition, if patients have supportive therapy this could prevent disease progression.
While there are options available for the treatment of peri-implantitis, uncertainties remain about these treatments. Initial improvements have been observed but there is limited knowledge as to whether they can be sustainable over the long term. The question remains – if these treatment options are followed, can further loss of implant-supporting bone be prevented?
In light of research and subsequent analysis, prevention seems the best course of action. The hygienist should be involved in preparing the patients for implants, making them aware of the risk factors, monitoring implant and periodontal health, as well as providing a regular, structured, supportive therapy programme.
Kotsovilis S, Karoussis IK, Trianti M, Fourmausis I (2008) Therapy of peri-implantitis: a systematic review. Journal of Clinical Periodontology 35: 621-629
Roos-Jansaker AM, Renvert S, Edgelberg J (2003) Treatment of peri-implant infections: a
literature review. Journal of Clinical Periodontology 30: 467-485
Roos-Jansaker AM et al (2006) Nine- to 14-year follow-up of implant treatment. Part I: implant loss and associations to various factors. Journal of Clinical Periodontology 33: 283-289
Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S (2006) Nine- to 14-year follow-up of implant treatment. Part II: presence of peri-implant lesions. Journal of Clinical Periodontology 33: 290-295
Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S (2006) Nine- to 14-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions. Journal of Clinical Periodontology 33: 96-301
Rotar A et al (2001) Retrospective assessment of clinical and microbiology factors affecting peri-implant tissue conditions. Clinical Oral Implant Research 12(3): 189-95