Figure 1. Comparison of crestal gingival fiber orientation.

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1 70 Test 75.2 IMPLANTS Oral Hygiene and Maintenance of Dental Implants Lee H. Silverstein, DDS, MS Gregori M. Kurtzman, DDS Figure 1. Comparison of crestal gingival fiber orientation. In more recent years, maintenance and effective patient home care have been emphasized as two critical factors needed for long-term success of dental s. Figure 2. Microscopic comparison of gingival fiber orientation (natural tooth on left, on right). Figure 3. Gingival fibers between 2 natural teeth showing orientation perpendicular to the long axis of the teeth. Long-term predictability of dental s and their associated restorations has been demonstrated. 1-3 As the number of patients treated with dental s continues to grow, dentists must accept the challenges of maintaining these sometimes complex restorations. Proper monitoring and maintenance is essential to ensure the longevity of the dental and its associated restoration through a combination of appropriate professional care, evaluation, and effective patient oral hygiene. 4,5 The value of using conventional periodontal parameters to assess peri health has not been completely defined. 4 Therefore, it is important that clinicians understand the similarities and distinctions between the dental and the natural tooth. Subsequently, by examining the similarities and differences between a natural tooth and a dental, basic guidelines can be provided for maintaining the longterm health of dental s. Direct anchorage of an to alveolar bone provides a foundation to support a dental prosthesis and transmits occlusal forces to the alveolar bone. This is the definition of osseointegration. 6 Recently, the focus of dentistry has expanded from obtaining osseointegration, which is highly predictable, to include the long-term maintenance of health of the peri- hard and soft tissues. This can be achieved through appropriate professional care and patient cooperation via effective home care. 7 Patients must accept the responsibility for maintenance, therefore the patient selection process should take into account the patient s willingness to maintain the fixture and restoration. Diagnosis and treatment planning based on a risk-benefit analysis should be performed subsequent to a thorough medical, dental, head-and-neck, psychological, temporomandibular joint, and radiographic examination. 8 Figure 4. Gingival fibers between 2 s showing orientation parallel with the long axis of the s. There is evidence that bacterial plaque not only leads to gingivitis and periodontitis, 9 but also can induce the development of periitis. 10 Thus, personal oral hygiene must begin at the time of dental placement and should include the use of various adjunctive aids to clean the altered morphology of the peri- region effectively DENTISTRY TODAY MARCH 2006

2 before, during, and after placement. For example, interproximal brushes can penetrate up to 3 mm into a gingival sulcus or pocket and may effectively clean the peri- sulcus. 11 In addition to mechanical plaque control, daily rinses using 0.1% chlorhexidine gluconate or Listerine (Pfizer) 12 may provide additional benefits. Effective oral hygiene around dental s can be challenging to achieve over the long term, and the patient, dentist, and dental hygienist must exercise considerable effort to achieve the desired results. During the maintenance visit, the dental professional should concentrate on the peri- tissue margin, body, prosthetic abutment-to- collar connection, and the prosthesis. 13 Clinical inspection for signs of inflammation (ie, bleeding on probing), exudate, mobility, and increased sulcus depth, and a radiographic evaluation of the peri- area still remain the standard approach to evaluating the status of endosseous dental s. For example, successful and stable endosseous dental s exhibit no mobility. But, if clinically perceptible mobility is detected, then subsequent to radiographic evaluation of the and its bony housing, the abutment retaining screw 14 and/or prosthetic abutment-collar interface should be examined for looseness or breakage. Therefore, different types of clinical assessment are used routinely, except for periodontal probing around peri- tissues that appear to be in a state of good health. The baseline data and data from subsequent maintenance visits should be recorded in the patient s chart to properly assess the peri- status over time. Subsequent to a thorough intraoral examination, unless there is visual evidence of soft-tissue changes (ie, inflammation of peri tissue with even slight attachment loss or mucositis), routine probing of the peri- tissue should not be performed. 15 continued on page 72 consult pro FREEinfo, circle 48 on card

3 72 IMPLANTS Oral Hygiene... continued from page 71 Figure 5. Plastic curettes for scaling dental s and demonstration of the surface after use. Note that there is no alteration to the surface. Figure 6. Plastic scaler used for recall maintenance. Figure 7. Alteration of surface after use of stainless steel scalers. Figure 8. Demonstration of gouging of the surface that may occur following use of an ultrasonic scaler. Figure 9. Demonstration of alteration of the surface following application of an air polisher and baking soda. Note the change in surface texture. Usually during the first year after the is restored, a 3-month maintenance schedule should be implemented, especially if the patient has lost teeth because of periodontal disease. However, if after 12 months the patient s s are stable and peri tissues are healthy, then a 4- to 6-month maintenance regimen can be implemented. 16 The clinician must be cognizant of each patient s level of home care effectiveness, systemic health, and status of the peri- tissues when determining these intervals. With dental patients, the dental professional must evaluate the prosthetic components for plaque, calculus, and the stability of the abutment. Radiographs of dental s should be taken every 12 to 18 months during these maintenance visits. 17 For dental restorations that are screw-retained, the clinician should remove the prosthesis at least once a year to more easily assess the status of the peri- hard and soft tissues, the existence of mobility of the prosthetic components or the fixture itself, and the patient s level of home care. 18 The presence of any signs of infection, radiographic evidence of peri- bone loss, and/or neuropathy may be indicative of an ailing or failing. 19 IMPLANTS VERSUS NATURAL TEETH It is essential that the clinician understands the relationship between the gingiva and the structure it attaches to, be it a natural tooth or an. (Figures 1 and 2) The fiber orientation of the gingival cuff around a natural tooth attaches perpendicular to the long axis of the tooth (Figure 3). This acts as a barrier when a periodontal probe is inserted into the sulcus. The probe tip advances apically until the tip contacts these fibers. This orientation is not observed around s. With an, the gingival fiber orientation is parallel to the long axis of the (Figure 4). When a periodontal probe is inserted into the sulcus around an, the probe tip advances, passing between the fibers of the gingival cuff until the crestal bone prevents it from advancing. The peri- mucosal seal may be a less effective barrier to bacterial plaque than the periodontal attachment around a natural tooth. 20 There is less vasculature in the gingival tissue surrounding dental s compared to natural teeth. This reduced vascularity, concomitant with parallel orientation of the collagen fibers adjacent to the body of the, makes dental s more vulnerable to bacterial insult. 21 During maintenance appointments, peri- periodontal probing should be performed only where signs of infection are present (ie, exudate, swelling, bleeding on probing, inflamed peri- soft tissue, and/or radiographic evidence of peri bone loss). Lastly, routine periodontal probing of dental s should not be performed, because this procedure could damage the weak epithelial attachment around the, possibly creating a pathway for the ingress of periodontal pathogens. 22 Commerically available plastic probes should be used when investigating the crevicular depth around dental s. The probing depth around dental s may be related closely to the thickness and type of mucosa surrounding the. A healthy peri- sulcus has been reported to range from 1.3 to 3.8 mm, which is greater than the depths reported for natural teeth. 23 The best indicator for evaluating an unhealthy site would be probing data gathered longitudinally. 24 For all of these reasons, personal home care and consistent professional maintenance have proven to be critical to the success and longevity of endosseous dental s. This is especially true in an environment with adjacent natural teeth, which if affected by periodontal disease could act as a reservoir for pathogenic bacteria and seed the peri- sulcus. 25 The physical characteristics of the peri- soft tissues should be the focus of oral hygiene instruction. The absence of keratinized tissue in this critical area has not been unequivocally documented to indicate that peri tissues are more vulnerable to the ingress of pathogenic bacteria. However, the ability of the patient to maintain good home care around dental s is facilitated by the presence of keratinized tissue surrounding them. Thus, if a patient has no keratinized tissue around an, and a pull from a frenum or a chronic peri- mucositis exists, then placement of a soft-tissue autogenous or allogeneic connective tissue graft is recommended to facilitate proper mechanical oral hygiene. 26 Specific clinical criteria associated with dental s that should be monitored for an indication of early failure have not been clearly defined. Currently, the presence of fixture mobility is the best indicator of failure. 27 Differing from natural teeth, healthy dental s exhibit no mobility because of the absence of a periodontal ligament. Therefore, healthy s should appear nonmobile even in the presence of peri- bone loss, if an adequate amount of supporting alveolar bone still exists. 28 When monitoring the health of the peri- soft tissues, the practitioner should be looking for changes in soft-tissue color, contour, and consistency. The presence of a fistulous tract is a serious clinical sign and could indicate the presence of serious pathology or fracture. 29 BLEEDING ON PROBING There is controversy in the literature as to the accuracy and significance of bleeding on probing around dental s. 30 Presently, the literature suggests that detection of bleeding on probing can be used as an early indicator of peri- disease or concurrently with other signs of failure, ie, bone loss. However, as previously mentioned, routine probing is not recommended. 31 RADIOGRAPHIC EVALUATION Radiographic assessment is one of the most useful means of evaluating the status of an DENTISTRY TODAY MARCH 2006

4 IMPLANTS XXX 73 endosseous dental. Invasion of biologic width, predictable remodeling, or socalled saucerization is associated with an average marginal bone loss of 1.5 mm during the first year following prosthetic rehabilitation. 32, 33 This is followed by an average of 0.2 mm of vertical bone loss in each subsequent year. 34, 35 Thus, progressive bone loss around a dental that exceeds these averages may be indicative of an ailing or failing. Lastly, during radiographic evaluation, no evidence of a peri- radiolucency (a radiolucent area between the and surrounding bone) should be found, because such a rarefaction usually indicates infection or failure to osseointegrate. 36 nicians suggest the use of a sonic instrument with a plastic sleeve over the tip for scaling dental s. 40 Air powder polishing units may also damage the surface and should not be used for s (Figure 9). Even the use of baking soda powder in these units may strip the surface coating from the. Additionally, the air pressure from these units may detach the soft-tissue connection with the coronal portion of the, leading to emphysema. 41 Titanium or titanium alloy surfaces of dental s can be polished using a rubber cup with a nonabrasive polishing paste or a gauze strip with tin oxide. Not only is the hygiene armamentarium important, but so are the home care techniques used to maintain endosseous dental s. Pa- continued on page 74 PROFESSIONAL CLEANING INSTRUMENTATION Instruments made of metal, such as stainless steel, should not be used to probe or scale dental s. The reason is that the metal can scratch or contaminate the surface, or cause a galvanic reaction at the -abutment interface. 37 Hand scalers for cleaning dental s can be plastic, Teflon, gold-plated, or made of wood (Figures 5 and 6). 38 When using gold-plated curettes, the manufacturer recommends not sharpening these instruments, as the gold surface could be chipped, exposing the harder metal underneath the coating. Stainless steel scaling instruments may abraid the surface, stripping off any surface coatings such as hydroxyapatite (HA), as the instrument s hardness is greater than the titanium alloy from which the is fabricated (Figure 7). Other commonly used devices and materials contraindicated for use with dental s are sonic and ultrasonic scaling units, air powder abrasive units, and flour or pumice for polishing. 39 Ultrasonic, piezo-electric, or sonic scaler tips may mar the s surface, leading to microroughness and plaque accumulation. The stainless steel tip may also lead to gouging of the s polished collar (Figure 8). However, some cli- astra tech FREEinfo, circle 49 on card

5 74 IMPLANTS Oral Hygiene... continued from page 73 Figure 10. Plastic-coated interproximal brush applied around abutments and under the superstructure for plaque removal. tients should be taught the modified bass technique of brushing using a medium-sized head, soft-bristled toothbrush. Patients should be instructed in the proper use of interdental brushes. The plastic-coated wire brush is the only type of interdental brush to be used with dental s, since these brushes will not scratch the surface (Figure 10). Recently, automated or electric toothbrushes have been advocated for daily home care. These devices may be rotary, circular, or sonic in design. The key to their effectiveness is proper instruction in their use, and then diligent daily use by the patient. As with natural dentition, adjunctive cleaning aids such as flossing are still valuable. An patient s home care regimen should be individually tailored according to each patient s needs. These needs are based on the location and angulation of the dental s, the position and length of transmucosal abutments, the type of prosthesis, the dexterity of the patient, and the rate of plaque and calculus accumulation. Another popular category of cleansing device is the oral irrigator, used with or without an antimicrobial solution. Studies have suggested that the addition of certain antimicrobials to the lavage during ultrasonic instrumentation or administered by subgingival irrigation following scaling and root planing have demonstrated minimal clinical benefit, with microbiota rebounding to levels found with scaling and root planing therapy alone. 42,43 However, oral rinses with antimicrobial properties, such as Listerine or chlorhexidine, have been advocated for use in patients with s SUMMARY When dental s were first introduced, the emphasis for long-term success was on the surgical phase of treatment. Subsequently, the emphasis changed from a focus on the surgical technique to proper fixture placement, which would be dictated by the prosthetic and aesthetic needs of each patient. In more recent years, maintenance and effective patient home care have been emphasized as two critical factors needed for long-term success of dental s. metalift FREEinfo, circle 50 on card Acknowledgment The authors would like to thank Dr. Emma Galvan for her editorial assistance with this article. References 1. Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated s in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10: Cox JF, Zarb GA. The longitudinal clinical efficacy of osseointegrated dental s: a 3-year report. Int J Oral Maxillofac Implants. 1987;2: Albrektsson T, Branemark PI, Hansson HA, et al. Osseointegrated titanium s. Requirements for ensuring a long-lasting, direct bone-to- anchorage in man. Acta Orthop Scand. 1981;52: Orton GS, Steele DL, Wolinsky LE. Dental professional s role in monitoring and maintenance of tissue-integrated prostheses. Int J Oral Maxillofac Implants. 1989;4: Bauman GR, Mills M, Rapley JW, et al. Clinical parameters of evaluation during maintenance. Int J Oral Maxillofac Implants. 1992;7: Rateitschak KH, Wolf HF, Spiekermann H, et al, eds. Color Atlas of Dental Medicine - Implantology. Stuttgart, NY: Thieme Publishing Group; 1995: Meffert RM, Langer B, Fritz ME. Dental s: a review. J Periodontol. 1992;63: Meffert RM. Treating the Ailing Implant. In: Misch CE, ed. Contemporary Implant Dentistry. St Louis, Mo: Mosby Year Book; 1993:chap Warrer K, Buser D, Lang NP, et al. Plaque-induced peri-itis in the presence or absence of keratinized mucosa: an experimental study in monkeys. Clin Oral Implants Res. 1995;6: Lang NP, Karring T. Proceedings of the 1st European Workshop on Periodontology. Chicago, Ill:

6 IMPLANTS 75 Quintessence; Balshi TJ. Hygiene maintenance procedures for patients treated with the tissue integrated prothesis (osseointegration). Quintessence Int. 1986;17: Ciancio SG, Lauciello C, Shibly O, et al. The effect of an antiseptic mouthrinse on maintenance: plaque and peri- gingival tissues. J Periodontol. 1995;66: Garg AK. Practical Implant Dentistry. Dallas, Tex: Taylor Publishing Co: 1995: Lekholm U, Ericsson I, Adell R, et al. The condition of the soft tissues at tooth and fixture abutments supporting fixed bridges: a microbiological and histological study. J Clin Periodontol. 1986;13: Lang NP, Nyman SR. Supportive maintenance care for patients with s and advanced restorative therapy. Periodontol ;4: Consensus report. Implant therapy II. Ann Periodontol. 1996;1: Baumgarten HS, Chiche GJ. Diagnosis and evaluation of complications and failures associated with osseointegrated s. Compend Contin Educ Dent. 1995;16: Meffert RM. In the spotlight: ology and the dental hygienist s role. J Practical Hygiene. 1995;September: Meffert RM. How to treat ailing and failing s. Implant Dent. 1992;1: Weyant RJ. Characteristics associated with the loss and peri- tissue health of endosseous dental s. Int J Oral Maxillofac Implants. 1994;9: Nevins M, Langer B. The successful use of osseointegrated s for the treatment of the recalcitrant periodontal patient. J Periodontol. 1995;66: Lang NP, Wetzel AC, Stich H, et al. Histologic probe penetration in healthy and inflamed peri- tissues. Clin Oral Implants Res. 1994;5: van Steenberghe D, Klinge B, Linden U, et al. Periodontal indices around natural and titanium abutments: a longitudinal multicenter study. J Periodontol. 1993;64: Quirynen M, van Steenberghe D, Jacobs R, et al. The reliability of pocket probing around screw-type s. Clin Oral Implants Res. 1991;2: Mombelli A, Marxer M, Gaberthuel T, et al. The microbiota of osseointegrated s in patients with a history of periodontal disease. J Clin Periodontol. 1995;22: Artzi Z, Tal H, Moses O, et al. Mucosal considerations for osseointegrated s. J Prosthet Dent. 1993;70: Cochran D. Implant therapy I. Ann Periodontol. 1996;1: Papaioannou W, Quirynen M, Nys M, et al. The effect of periodontal parameters on the subgingival microbiota around s. Clin Oral Implants Res. 1995;6: Silverstein LH, Meffert RM, Jeffcoat M, et al. Clark s Clinical Dentistry. Vol 5. St Louis, Mo: Mosby Year Book; chap 62A Clinicians guide to peri ology Garnick JJ, Silverstein L. Periodontal probing: probe tip diameter. J Periodontol. 2000;71: Garnick JJ, Silverstein LH. Clark s Clinical Dentistry. Vol 3. Philadelphia, Pa: JB Lippincott; chap 2B Periodontal probing. What does it mean? 1997: Misch CE. Contemporary Implant Dentistry. St Louis, Mo: CV Mosby; 1993: Roberts WE, Garetto LP. Bone physiology and metabolism. In: Misch CE, ed. Contemporary Implant Dentistry. 2nd ed. St Louis, Mo: Mosby; 1999: Oh TJ, Yoon J, Misch CE, et al. The causes of early bone loss: myth or science? J Periodontol. 2002;73: Misch CE. Density of bone: effect on treatment plans, surgical approach, healing, and progressive bone loading. Int J Oral Implantol. 1990;6: Apse P, Ellen RP, Overall CM, et al. Microbiota and crevicular fluid collagenase activity in the osseointegrated dental sulcus: a comparison of sites in edentulous and partially edentulous patients. J Periodontal Res. 1989;24: Speelman JA, Collaert B, Klinge B. Evaluation of different methods to clean titanium abutments. A scanning electron microscopic study. Clin Oral Implants Res. 1992;3: Gantes BG, Nilveus R. The effects of different hygiene instruments on titanium surfaces: SEM observations. Int J Periodontics Restorative Dent. 1991;11: Rapley JW, Swan RH, Hallmon WW, et al. The surface characteristics produced by various oral hygiene instruments and materials on titanium abutments. Int J Oral Maxillofac Implants. 1990;5: Gantes BG, Nilveus R. The effects of different hygiene instruments on titanium surfaces: SEM observations. Int J Periodontics Restorative Dent. 1991;11: Meffert RM. Treatment of failing dental s. Curr Opin Dent. 1992;2: Reynolds MA, Lavigne CK, Minah GE, et al. Clinical effects of simultaneous ultrasonic scaling and subgingival irrigation with chlorhexidine. Mediating influence of periodontal probing depth. J Clin Periodontol. 1992;19: Silverstein LH, Schuster GS, Garnick JJ, et al. Bacterial penetration of gingiva in the adult beagle dog with periodontitis. J Periodontol. 1990;61: Mombelli A, Lang NP. Antimicrobial treatment of peri- infections. Clin Oral Implants Res. 1992;3: Ciancio S. Expanded and future uses of mouthrinses. J Am Dent Assoc. 1994;125(suppl 2):29S-32S. 46. Garg AK, Duarte F, Funari K. Hygienic maintenance of dental s: the key to long-term success. J Practical Hygiene. 1997;6: Dr. Silverstein is an associate clinical professor of periodontics at the Medical College of Georgia in Augusta. He is on the editorial boards of Practical Periodontics and Aesthetic Dentistry, Dentistry Today, and Esthetique, a direct-toconsumer aesthetic topics publication. He also maintains a private practice limited to periodontal care and dental s in Atlanta at Kennestone Periodontics, PC. He recently published the textbook, Principles of Dental Suturing: A Complete Guide to Surgical Closure. Dr. Silverstein can be reached at (770) , via fax at (770) , or by to [email protected]. Dr. Kurtzman is in private practice in Silver Spring, Md, and is an assistant clinical professor at the University of Maryland School of Dentistry, Department of Restorative Dentistry. He is on the editorial board of the Journal of Oral Implantology, an assistant editor of the International Magazine of Oral Implantology, and editor of the Maryland Chapter newsletter of the Academy of General Dentistry. He can be contacted at [email protected]. Continuing Education Test No To submit Continuing Education answers, use the answer sheet on page xx. On the answer sheet, identify the article (this one is Test 75.2), place an X in the box corresponding to the answer you believe is correct, detach the answer sheet from the magazine, and mail to Dentistry Today Department of Continuing Education The following 8 questions were derived from the article Oral Hygiene and Maintenance of Dental Implants by Lee H. Silverstein, DDS, MS, and Gregori M. Kurtzman, DDS, on pages 70 through 75. Learning Objectives After reading this article, the individual will learn: the importance of professional and home hygiene care for dental patients, and professional and home hygiene care techniques for dental patients. Routine probing of s. a. is not recommended in the absence of the signs of inflammation or mobility b. should be performed at each recall appointment c. is used for monitoring the health of the d. all of the above Radiographic monitoring of bone levels should be performed. a. every 12 to 18 months b. 3 months following restoration of the c. at each hygiene appointment d. every 18 to 24 months Peri-itis has been associated with. a. bacterial plaque b. mobility of the c. gingival inflammation d. all of the above Bone loss of 1.5 mm during the first year following placement of the is. a. considered a sign of peri-itis b. normal c. a sign of occlusal overload of the d. both a and c Continuing our Journey of Excellence A stainless steel scaler may. a. remove surface treatment (ie, HA) from the surface b. scratch the titanium surface c. assist in removing calculus from the sulcus d. a and b Presence of a fistula may indicate. a. fracture of the b. pathologic process associated with the c. A fistula cannot be associated with the because the is not a biological device. d. a and b With regard to s, electric toothbrushes. a. should not be used, as they may loosen fixation screws b. may damage the surface c. are a good adjunct to home care d. are not as effective as a manual toothbrush The peri-mucosal seal around s versus natural teeth. a. is similar b. is weaker around natural teeth c. is weaker around s d. varies from patient to patient MARCH 2006 DENTISTRY TODAY