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Home Care for the Implant Patient
Marisa Roncati
Department of Translational Medicine, School of dentistry, University of Ferrara, Ferrara, Italy
Introduction and Key Issues
The following statements schematically summarize the premises as well as represent a number of absolutely significant conclusions, therefore proposed as an introduction to the chapter.
- Proper home care for effective plaque removal is undeniably crucial for the prevention, management, and control of peri‐implant infections, induced by bacterial biofilm [1–6].
- The mechanism of biofilm formation and the role of the peri‐implant microbiome is a core component in preventing most biologic complications [6].
- Poor oral hygiene and lack of regular maintenance are strongly correlated with the development of both peri‐implant mucositis and peri‐implantitis [7].
- Implants should be placed only in patients who can master oral hygiene skills required for disease prevention and already adhering to a recommended and tailored recall frequency (Figures 22.1–22.9).
- It is extremely valuable to emphasize that implant placement and prosthetic reconstructions need to allow proper personal cleaning, diagnosis by probing (Figures 22.3 and 22.7) and professional plaque removal [8].
- A dedicated dental team must inform the patient about the need for a constructive therapeutic alliance and educates patients to mechanically and efficiently remove biofilm (Figures 22.4, 22.6, 22.9) [9].
- Home care for the implant patient is still extensively neglected or delegated, but it is an indisputable cause of success [10] or failure even in case of implant treatment [11].
- It is valuable to properly coach the patient on how to use dedicated home care tools and more importantly in adjunct to routine oral care procedures. Dental implants require some additional tools beyond routine oral hygiene care.
- The patient should be instructed to always begin daily oral hygiene from implant–supported restorations.
- The presence of an “adequate” amount of peri‐implant keratinized mucosa is beneficial to improving proper daily oral care [3, 12].
- Various other factors can affect home care efficacy: tissue anatomy, periodontal status, or phenotype [3].
- At each follow‐up recall appointment the clinician must update the diagnosis (Figures 22.3 and 22.7) and continually remotivate the patient after assessing home care performance [9].
- Consider implant subjects always “high‐risk” patients.
- Peri‐implant diseases are frequent and prevalence of peri‐implantitis is increasing over time [8, 13]. As peri‐implant diseases could be effectively controlled by accurate prevention, the importance of giving proper oral hygiene instructions to the patients who are rehabilitated with dental implant and of fitting prosthetic constructions that allow accessibility for oral hygiene around implants [14–16] is not stressed enough.
Rationale and Relevance of Home Care
In implant dentistry, plaque control and oral hygiene practices are essential to limit the risk of complication and failure in the long term [3]. The identified etiological factor is certainly the biofilm [1].
Home care is the most important factor in impacting prevention, treatment, and prognosis of complications [11, 17].
However, effective Oral Hygiene remains a daily challenge.
Figure 22.1 (a–b). Full mouth X‐ray before (a) and twenty years after (b) implant treatment in the posterior sectors.
Figure 22.2 Clinical case aspect with a 20‐year follow‐up.
A considerable body of evidence indicates that patients with implant–borne removable and fixed restorations require lifelong professional recall regimens to provide home care instructions, biological and mechanical maintenance, customized for each patient [18].
Experimental biofilm accumulation leads to a higher frequency of bleeding sites around implants as compared with teeth [19]. Consequently, in the case of a positive bleeding index, the clinician is responsible for providing site‐specific recommendations so that, in addition to professional hygiene, proper home care can resolve plaque‐induced inflammation.
Neglected or poorly treated periodontal disease increases the threat for peri‐implantitis and implant loss [20]. Prevalence of peri‐implantitis is higher in noncompliant patients demonstrating poor home care adherence. Patients with a history of periodontitis presented lower survival rates and a statistically significantly higher number of sites with peri‐implant bone loss [20]. A higher implant failure rate was found in periodontally compromised patients who did not completely adhere to the recommended supportive periodontal therapy and showed improper home care [20].
Figure 22.3 (a–b). The periodontal probe detects normal probing values in the absence of bleeding. The clinician should always update the diagnosis at each recall appointment by circumferential probing.
Figure 22.4 Electric toothbrush with oscillating‐rotating technology (Oral B Procter and Gamble Company, USA). It is crucial to teach the patient proper brushing technique to ensure effective biofilm removal while preserving peri‐implant tissue integrity.
Lack of regular supportive therapy in patients with peri‐implant mucositis is associated with increased risk for onset of peri‐implantitis [8].
These important concepts should be highlighted: the periodontal patient is at greater risk of complications than periodontally healthy patients [9]. Consequently, all implant patients should be considered at high risk.
In contrast, stable clinical results could be achieved up to five years after initial therapy but adequate oral cleanliness across this period appeared to be an essential prerequisite [21, 22].
Figure 22.5 (a–b). Clinical use of a tritonal plaque disclosing solution (a) (Tri Plaque ID Gel, GC Corporation, Tokyo, Japan), to more effectively highlight the biofilm to be removed (b).
Figure 22.6 (a–b). Clinical use of a very useful and practical gauze soaked in 0.12% chlorhexidine (Digital Brush, Enacare, Micerium, Avegno, GE, Italy), wrapped around the finger of the dominant hand (a). The medicated gauze is initially placed on the keratinized gingiva or on the alveolar mucosa and then rolled in an apico‐coronal direction, as indicated by the arrow (a). This procedure results in effective biofilm removal respecting the integrity of the peri‐implant soft tissues. In addition, the use of the gauze is supplemental to the brushing (b).
Figure 22.7 (a–b). Normal probing values are also recorded in the right posterior mandibular area, after 20 years of follow‐up from implant treatment.
Figure 22.8 (a–b). Plaque disclosing solution (Tri Plaque ID Gel, GC Corporation, Tokyo, Japan) is applied with a micro brush (a). Clinical appearance after rinsing with the air‐water syringe (b). The clinician thus has the opportunity to motivate the patient to rigorously cleanse the residual biofilm (b).
Figure 22.9 (a–b). The interproximal toothbrush is the most appropriate tool for the removal of microbial biofilm from the interdental site. It is important to teach the patient to insert it correctly with an oblique movement in the apico‐coronal direction (Interdental brush, Enacare, Micerium, Avegno, GE, Italy).
Therefore, home care reinforcement is so crucial to control reinfection and limit biologic complications, enhancing the long‐term outcomes of implant therapy, particularly in patients with previous history of periodontitis [23].
The paramount importance of periodontal treatment with the goal of complete resolution of any periodontal inflammation before implant placement in partially edentulous patients has been highlighted throughout the dental literature [24, 25].
Prevention is the ideal treatment of peri‐implantitis It is also advisable to begin supportive peri‐implant therapy before positioning the implant. Patients must receive detailed and, above all, personalized instructions on home care procedures based on their particular clinical situation, including any hopeless teeth planned for extraction, prior to implant placement [9]. Use of medicated gauze or a digital brush (Figure 22.6 a) is recommended for hopeless teeth [9, 11].
Periodontal pathogens can be transmitted from natural teeth to implant; therefore, meticulous oral hygiene regimens of the entire oral cavity are an indispensable prerequisite.
The soft‐tissue conditions around the implant, the width of keratinised mucosa, and the phenotype and thickness of the mucosa are also considered major risk indicators, as the presence of any mucosal defect around an implant can increase plaque accumulation and result in tissue inflammation [3].
As periodontists became concerned about cleanability and ease of hygiene with mucosal margins around implants, further revisions in techniques focused on the importance of the preservation of attached gingiva for maintenance of the implants [26].
Most clinicians agree that an “adequate” amount of attached gingiva facilitates proper daily oral care [3, 12].
The prosthetic suprastructure design and the possibility for the patient to easily access each implant for plaque removal is crucial [3]. The coronal portion of the implant, which is exposed to the bacterial challenge of the mouth, should be smooth enough not to foster plaque accumulation [26].
How to Motivate and Inform Implant Patients on Effective Home Care
Implants patient education must be the combined team efforts of the dental office staff and patients themselves for long‐term success of dental implantology.
The clinician must ascertain the patient’s awareness and understanding that effective oral hygiene is absolutely crucial. Poor oral hygiene resulting in plaque accumulation leads to peri‐implant disease [27].
The patient should also be informed that peri‐implant tissues respond to plaque accumulation in a way similar to that of periodontal tissues and that disease may develop in the tissues around the implants jeopardizing their longevity [27].
Implant–supported prosthetic restorations are more vulnerable to plaque‐induced inflammation. Such concept is well known by all clinicians; however, the question is: do we do enough [9]?
In other words, do we as patient educators, do as much patient training in oral hygiene as necessary? Special awareness should be devoted to exemplifying tactics for the patient’s approach to achieve appropriate plaque control, reinforcing desirable behaviors and producing results in a short time.
Always strengthen motivation at every possible opportunity, asking commitment to change, for autonomy and not with authority, and especially boost self‐efficacy.
It is important to make the patient aware that dental health care habits, such as brushing and interdental cleaning, are crucial for long‐term maintenance.
Patients should be guided in the selection of instruments best suited to their individual needs and trained in their use so to perform proper daily oral hygiene care [9].
During all subsequent sessions, it is essential to assess oral hygiene status and check if the cleaning procedures applied are actually appropriate, offering additional home care reinforcement or changing tools and techniques as needed [9].
A dedicated clinician educates patients to mechanically remove biofilm. Invest time in demonstrating how to brush teeth/implant–supported restorations properly either with an electric or manual tooth brush.
Dental office staff devote time to teaching interproximal hygiene techniques with the proper instrument for the existing interdental dimension.
Emphasize to start brushing from posterior areas, frequently hosting implant–supported restorations (Figure 22.10).
People usually brush their teeth with special attention to the anterior areas, both as a matter of habit and because of cosmetic considerations. Consequently, the posterior teeth and particularly the palatal and lingual surfaces are brushed hastily [9].
Suggest specific and dedicated implant care, i.e. the patient should use a supplementary tool, and/or add some extra antimicrobial/antiseptic substance, or specific toothpaste for implants beyond the appropriate routine for natural teeth.
There is consensus that prevention is more necessary than cure.
Figure 22.10 Implants are frequently inserted in the posterior sectors, especially in periodontal patients who have replaced completely compromised teeth. The clinician should always recommend starting the brushing maneuver from the areas where the implants are placed, and particularly from the palatal and/or lingual aspect, as indicated in the drawing. In the initial stages of brushing, the patient should be more careful and meticulous for effective biofilm removal precisely at those sites most vulnerable to plaque‐induced inflammation.
Even in the case of implant treatment an adequate prevention could avoid plaque‐induced peri‐implant diseases. Nevertheless, peri‐implant inflammatory complications are increasing, so the strategies that should modify this trend, according to the author, would be: convince the patient to use additional tools, always giving priority to the cleansing of areas where implant reconstructions are located.
Advise patients that mouthwash rinsing is ineffective for adhesive microbial plaque.
When we began to successfully place dental implants, the entire surgical team, adopted a strict protocol, provided by Branemark, including an intra‐oral pre‐operative chlorhexidine “scrub.”
The take home message is to educate the population to a mechanical removal of biofilm.
During the infancy years of dental implantology, the emphasis for long‐term success of osseointegrated implants was the surgical phase [28]. In the years that followed, the significance for long‐term maintenance had switched to focusing more on the proper fixture placement, dictated by the prosthetic and aesthetic needs of each specific case. In more recent years, professional implant maintenance [18] and meticulous patient home care [17] has been recognized as two critical factors for the long‐term success of dental implants.
Bleeding on probing is considered as key clinical measure to distinguish between peri‐implant health and disease [8].
Consequently, wherever bleeding on probing is detected, the entire dental team must be involved in scheduling a suitable time to remotivate the patient in order to effectively remove the biofilm and resolve plaque‐induced inflammation.
Dental assistants and dental hygienists have a significant role in the education of implant patients so that meticulous oral self‐care can be accomplished. However, it is important that dentists do not give the impression that they are delegating the motivation phase only to auxiliary personnel. On the other hand, the dentist should emphasize the importance of giving first‐hand instructions and participating in the practical sessions of oral hygiene instruction.
The clinician should NOT GIVE THE FEELING to DELEGATE OHI.
Current evidence also demonstrates that the use of specific oral topical agents and oral hygiene aids can improve professional and at‐home maintenance of implant–borne restorations.
Current evidence also demonstrates that the use of specific oral topical agents and oral hygiene aids can improve professional and at‐home maintenance of implant–borne restorations.
Current evidence also demonstrates that the use of specific oral topical agents and oral hygiene aids can improve professional and at‐home maintenance of implant–borne restorations [18].
How Much Time Should be Spent on Motivation?
It is recommended that the 1st appointment of etiological therapy of all implant patient should last 2 hours, so at least 20/30 minutes can be devoted to motivation and very thorough home oral hygiene instructions.
Approximately 15 minutes at subsequent appointments should be scheduled to remotivating the patient and assessing his/her home care performance efficacy, based on instructions given at the previous appointment.
During periodontal support therapy, motivation time ranges from 5 to 15 minutes, depending on the level of patient compliance.
These times are approximate; all patients deserve their own personalized reinstruction sessions when indicated. It is always important to set aside enough time to explain the home care techniques: the therapist needs to make certain that the patient has mastered the oral hygiene skills.
Most importantly, it is imperative that the oral hygiene instructions be practical, i.e. the clinician must demonstrate the proper use of the hygiene instruments in the patient’s mouth, and then supervise home care procedures to ensure the patient is able to implement all the techniques correctly.
The clinician must not assume that once the instructions are given, the patient will remember them in all their details, for long time.
Continuous Patient Remotivation is a Never‐Ending Job.
Audiovisual educational materials are recommended as a supplement to home oral hygiene explanations.
The author has released a DVD in Italian addressed to the patient, with the catchy title: “If I say implant, what do you think?,” focused mainly on the motivation of the patient, as well as providing useful practical information especially in the short and long term post‐surgical follow‐up [29].
Essential Home Care Tools and Technique
A plethora of home care tools have become commercially available.
To keep high compliance, clinician should avoid overwhelming the patient with several devices or complicated protocols, most of which, other than brushing, are dropped following a short trial period [9].
Therefore, only the essential instruments should be selected, fully describing the technique to effectively using them.
It is crucial to recommend to the implant patient the following [9]:
- Effective brushing technique (with manual or electric toothbrush).
- An interproximal cleaning aid (definitely an interdental brush). Oral hygiene should always include an interproximal device, which could be either an interdental brush or dental floss (Figures 22.19–22.22), depending on interproximal space viability and width.
- An additional home care device. (e.g. a Digital Brush, Enacare, Micerium) [9] The patient should always use some extra instrument, specific to the area where the implants have been placed, in addition to the oral hygiene routine for the rest of his or her mouth.
Home care effectiveness is mainly determined by the dexterity of the patient. Therefore, the technique used is more important than the instrument selected, which must be appropriate for the peri‐implant site.
In terms of patient‐centered care, the presence of a peri‐implant keratinized tissue is beneficial to easing proper oral hygiene. The keratinized mucosal collar offers greater resistance to possible trauma resulting from brushing maneuvers and the use of auxiliary tools such as interdental brushes, tufts, and special flosses [12].
Figure 22.11 (a–e) The periodontal probe detects 2 mm probing depth on the mesial aspect (a) and 3 mm on the distal aspect (b), both in the absence of bleeding (a–b), of the implant replacing the left maxillary lateral incisor. The peri‐implant tissue is in good health, although keratinized gingiva is absent in this clinical case at 19‐year follow‐up (a–b). The patient’s oral hygiene is satisfactory. In addition to tooth‐ and interdental‐brushing, the patient uses a special implant toothpaste (Implaclean®, Dyna Dental, Netherlands), which can also be applied by the clinician with a micro brush (c–e) or at home by the patient with a single tufted toothbrush. It is important to train the patient to use a specific tool and especially additional to routine oral care methods.
This is crucial especially for less motivated patients, who could justify their oral hygiene negligence if they are experiencing localized discomfort or soft tissue lesions following self‐injury due to inappropriate tool use. This does not mean that oral hygiene maneuvers cannot be carried out effectively if the peri‐implant keratinized mucosa is minimal or even absent, but they are undoubtedly more difficult to perform properly [12]
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