When I began my dental career, dental implants were not as common as they are today. As a consequence, we had limited knowledge on the best maintenance protocols for these implants. One message was clear…do not scratch, harm, or alter the implant surface. The intense concern that we might damage the implant and doom it to failure, led many hygienists to perform a ‘polish and pray’ prophy. We treated the natural dentition, avoided the implant except to polish and floss, then prayed we did no harm. Today’s maintenance visit is very different. Below are my first four steps in evaluating the health of a dental implant.
Step 1: Ask the Patient
The first step in evaluating an implant’s health is to ask the patient how the area feels. A dental implant should feel like nothing to the patient. If there is a problem, patients may feel some pain and aches. Most commonly, patients will report a ‘sensation’. They don’t describe it as pain but an awareness of the implant area that they hadn’t experienced before. This reported sensation is a reason to evaluate the implant closely.
Step 2: Observe
One of the first things to look for is the presence of keratinized epithelium, the quantity (mm) and quality (thin, thick). Although implants can be maintained with limited or no kepi, there is a growing industry understanding that 2 mm of kepi is ideal around dental implants. When only mucosa is present, the soft tissue is easily irritated by biofilm and the tissue may bleed during the patients home care routine. Many patients avoid areas of bleeding in fear they are causing problems, that leads to more biofilm accumulation and more soft tissue irritation. Knowing the type and quantity of soft tissue around an implant will help you to understand the potential for bleeding and inflammation. This will allow you to make appropriate home care. recommendations that do not add to the irritation of the mucosa and calm patient’s concerns about the implant’s heath.
Take a quick look at the buccal aspect of implant. Are you able to see the gray surface of the implant through the soft tissue? Being able to see the implant surface through the soft tissue means the buccal plate is thin or lost. Without bone support, the implant area is fragile. This is an important observation to note in the patient’s chart and the doctor (in good conscience) should explain the observation to the patient. The patient deserves to know the health of the implant and anything that may cause an issue in the future.
Step 3: Palpate
Due to the lack of supportive gingival fibers, the inflammatory war known as peri-implantitis has the ability to sink deeper into the soft tissues, eroding bone support. There are some soft tissue changes that may be noticeable but those tend to be very subtle and difficult to identify. The palpation of the buccal and lingual aspects of the implant, beginning at the apex and moving in a coronal direction, will be a more effective diagnostic step. The clinician may find exudate or blood expelling from the sub-gingival environment. This is a major clue that peri-implantitis may be present.
Step 4: Probe
To probe or not to probe, that has been the question for many years. During my dental hygiene infancy, it was widely accepted that probing was not an accurate diagnostic around dental implants and may be harmful to the peri-implant seal or the implant body. To this date, I have not found any documentation of an implant failing due to periodontal probing. It is possible to create some bleeding if the clinician probes with too much force. But, if the peri-implant seal is damaged, it should heal in a matter of days.
The recommendation is to use 0.25 N force when probing. It’s fabulous if you have calibrated yourself for this amount of pressure. This measurement means nothing to me as I have not discovered what 0.25 N feels like during probing. My process has been to envision the seal as a trampoline, using an extremely light touch, I allow the tightness of the soft tissue to push back my probe. This prevents me from pushing too hard and allows the probe to easily ‘fall’ into deeper pockets.
As for diagnostics, the information we gain from probing dental implants is slightly different than what we look for around natural teeth. Rather than looking for pocket depths greater than 3 mm, an increase in depth over time is a primary indicator of a loss of support around the implant. Noting exudate and bleeding upon probing are important factors around implants as they are around natural teeth.
It is important for an office to develop an implant care protocol that is accepted and performed by all of the hygienists. Clinicians need to be able to identify new recommendations or research and be able to apply that knowledge to every day clinical life. As dentistry moves away from treating dental implants as if they were natural teeth, and begins treating them as a prosthetic replacement for a natural tooth, changes in how we perform maintenance in the office and how the patient cares for the implant are sure to keep coming.