11
Periodontal Maintenance in Patients with Peri‐implantitis
Hanae Saito1, Caitlin Darcey2,3, and Mark A. Reynolds1
1 Department of Advanced Oral Sciences and Therapeutics, Division of Periodontics, University of Maryland School of Dentistry, Baltimore, MD
2 US Navy Periodontics Residency, Naval Postgraduate Dental School, Bethesda, MD
3 Uniformed Services University of the Health Sciences, Bethesda, MD
Introduction
Regular professional supportive oral health care is considered central to controlling the progression of inflammatory periodontal and peri‐implant disease. This chapter reviews the rationale, treatment approaches, and evidence for periodontal maintenance in patients with healthy implants and after active treatment for peri‐implantitis.
Periodontal maintenance (formerly referred to as Supportive Periodontal Therapy) is defined as procedures performed at selected intervals to assist in maintaining oral health in individuals with a history of periodontitis. Periodontal maintenance procedures following active therapy are not synonymous with a prophylaxis [1]. Periodontal maintenance (PM) is started after completion of active periodontal therapy, both non‐surgical and surgical therapies, and at varying intervals for the life of the dentition, including dental implants. Studies have demonstrated that periodontitis can be successfully treated by both non‐surgical and surgical protocols [2] as part of active periodontal therapy. However, the benefits of active periodontal therapy cannot be maintained without a regular program of PM [3].
Maintenance procedures are under the supervision of the dentist and typically include an update of the medical and dental histories, radiographic review, extraoral and intraoral soft tissue examination, dental examination, periodontal evaluation, removal of supragingival and subgingival bacterial plaque (biofilm) and calculus, selective root planing where indicated, polishing of the teeth, and a review of the patient’s plaque control efficacy [4, 5]. These procedures are performed at prescribed intervals established for periodic ongoing care to assist the patient in maintaining periodontal health. This phase of periodontal therapy focuses on the control of etiologic factors and monitoring of periodontal health status. It is distinct from, but integrated with, active periodontal therapy. Patients receiving PMT may require active therapy to control disease progression [6].
The traditional therapeutic goals of PM include (i) minimizing the recurrence and progression of periodontal disease in patients previously treated for gingivitis and periodontitis, (ii) reducing the incidence of tooth loss by monitoring the dentition and any prosthetic replacements of the natural teeth, and (iii) increasing the probability of locating and treating, in a timely manner, other diseases or conditions found within the oral cavity [7]. Since the goal of periodontal maintenance is to minimize the recurrence and progression of periodontitis, the authors propose that the protocols associated with traditional periodontal maintenance can be applied – with several specific considerations and modifications – to control the progression of peri‐implantitis.
In this chapter, Implant Maintenance (IM) is used to distinguish treatment approaches for the control of peri‐implantitis from PMT for the control of periodontal infection. Three common clinical scenarios are summarized below that help guide questions related to the application of IM:
- The patient without a history of periodontitis and peri‐implant mucositis/peri‐implantitis (“healthy” dental implants): Do dental implants increase the risk of developing periodontal infection and disease – periodontitis or peri‐implantitis?
- The patient with a history of peri‐implant mucositis: Is the temporal progression of peri‐implant mucositis to peri‐implantitis similar to that of gingivitis to periodontitis?
- The patient with a history of peri‐implantitis: (i) Is PM in a patient with periodontitis the same as IM in a patient with peri‐implantitis? (ii) What is the role of IM in the patient with active peri‐implantitis versus following active treatment of peri‐implantitis?
In consideration of the above scenarios, this chapter will discuss the rationale for IM, elements of an IM appointment, and guidelines for the determination of maintenance intervals.
Modifying Factors and Considerations
The current model of disease progression for periodontitis is well‐established and supported by decades of clinical evidence documenting the vital role of PM in controlling the progression of periodontitis – with lifelong maintenance, periodontitis can be stabilized for a vast majority of our patients [6]. With the increased use of dental implants to replace missing teeth, there has been a significant rise in prevalence of peri‐implant disease, with estimated weighted mean prevalence of 43% for peri‐implant mucositis and 22% for peri‐implantitis [8, 9]. The risk profiles associated with the progression of peri‐implant mucositis and peri‐implantitis resemble the risk profile that drives the progression of gingivitis and periodontitis. Therefore, similar strategies have been adopted from periodontal protocols for implant maintenance therapy to prevent further breakdown. For example, without supportive therapy, implant sites with peri‐implant mucositis are at risk for progression to peri‐implantitis [10] and those sites with peri‐implantitis risk further breakdown. Given the similarities in the clinical presentation of periodontitis and peri‐implantitis, it is reasonable to conclude that similar approaches to supportive care after treatment of peri‐implant disease should prove beneficial in controlling disease progression.
Multiple studies have investigated the impact of periodontal maintenance on the occurrence of peri‐implant diseases [11–13]. As with periodontal maintenance, a primary focus is on identifying and addressing host‐level and site‐specific (implant) factors in the personalized maintenance plan to an individual patient. The modifying factors and considerations of peri‐implant disease progression will be presented, organized into two main categories for the reader: host‐level and implant‐level considerations.
Host‐level
There are several host‐level considerations identified in the literature that are essential to review when prescribing an IM maintenance plan, such as a history of periodontitis, smoking, systemic diseases, e.g. type II diabetes mellitus, and poor plaque control [14].
Systemic Considerations
Although it might be intuitive to assume that systemic disease can have a significant impact on peri‐implant health, the evidence on whether specific systemic conditions are a risk factor for peri‐implant disease remains equivocal [14]. However, systemic conditions, such as uncontrolled diabetes, and environmental exposures, such as tobacco smoking and radiation therapy of the oral/head‐neck region, are generally considered factors with the potential to modify peri‐implant disease susceptibility and progression, including implant failure [6, 9, 15, 16].
Polymorphisms in genes for cytokines, such as IL‐1 and IL‐6, have been associated with an increase in the expression of these inflammatory cytokines and with the development of chronic diseases, such as periodontitis and peri‐implant disease [17]. The latter findings suggest that genetic background may also predispose certain individuals to implant failure, consistent with observations of multiple implant failures (cluster failure behavior) of implants at the patient level. Consideration of potential risk factors is important for the targeted management of peri‐implant disease and the long‐term stabilization of peri‐implant health [16, 17].
Additional host‐level factors that should be considered when building a peri‐implant maintenance plan are disturbances in cognitive function and advanced age [16, 18, 19]. There is evidence that loss of cognitive function and dementia negatively impact periodontal health due to an increase in plaque accumulation and bacterial burden; oral hygiene is further compromised from the barriers associated with cognitive decline and compromised dexterity [18]. Patients exhibiting a decline in cognition, dexterity, or both may benefit from shorter intervals between appointments, engagement of family or caretakers in oral hygiene care, and instruction on the use of oral hygiene devices, such as customized or electric toothbrushes and flossers, to help patients perform oral hygiene care. Contrast this situation with a patient who struggles with compliance because of their own lack of motivation or interest in oral hygiene. In this case, the patient is best treated with customized oral hygiene instruction that focuses on the justification for the emphasis on plaque control [6] to empower the patient to take responsibility for his/her oral health care ownership of factors within their control.
History of Periodontitis
Given that periodontitis and peri‐implant disease share similar risk profiles for disease progression, maintenance therapy is considered essential to reduce disease recurrence and progression following active therapy [6, 20]. Not only does periodontitis share risk factors with peri‐implant disease, but a history of periodontitis appears to predispose individuals to peri‐implant disease. Peri‐implantitis has been reported to be found twice as often in patients with periodontitis compared to those without periodontal disease; moreover, the extent of peri‐implant breakdown was shown to parallel the severity of the preexisting periodontitis [14, 21, 22]. Clinical studies have reported that a history of periodontitis prior to implant placement or the presence of residual periodontal pockets at the time of implant placement were associated with a higher occurrence of implant loss and peri‐implant diseases [11,22–24]. Residual deep probing depth (≥6 mm) and marginal bone loss constituted risk factors for recurrence/progression of peri‐implantitits. Furthermore, patients with an aggressive or molar/incisor pattern periodontitis may need additional active therapy following implant placement and should be also considered candidates for shorter recall intervals [10].
History of Peri‐implant Mucositis
As with the progression of gingivitis to periodontitis, it is acknowledged that peri‐implant mucositis can be a precursor to peri‐implantitis, often progressing in an accelerated pattern [15]. Without supportive therapy, implant sites with peri‐implant mucositis are at risk for progression to peri‐implantitis [10]. In a five‐year retrospective study in Brazil, patients diagnosed with peri‐implant mucositis at baseline had a significantly higher incidence of peri‐implantitis (43.9% versus 18.0%) if they attended less than one visit to the dentist annually [11]. These results are in agreement with the findings of a systematic review, which found a higher prevalence of peri‐implantitis in persons not receiving maintenance care compared to those undergoing routine follow‐up care (≈35% versus ≈10%, respectively) [5]. Patients in IM following active therapy for peri‐implantitis must be evaluated closely for of signs of inflammation, which could indicate peri‐implant mucositis or active peri‐implantitis.
Implant‐level
Bacterial Biofilm
Periodontal pockets are ideal environments for the establishment and maturation of subgingival biofilm [3]. The temporal relationship between inflammation, dysbiotic subgingival microbiota, and disease onset and progression remain incompletely understood [25]. Nevertheless, it is important to understand the dynamic role of the polymicrobial biofilm in disease pathogenesis [26]. Studies also highlight differences in bacterial profiles of healthy and diseased dental implants [27].
Socransky’s landmark study of periodontal disease identified six bacterial complexes that commonly occur together. For descriptive purposes, these complexes were color‐coded as blue, green, yellow, purple, orange, and red. The orange and red complexes are thought to be associated with periodontitis and include members of the yellow, green, and purple complexes [28]. The orange complex bacteria generally appear after the early colonizers and include many putative periodontal pathogens, such as Fusobacterium nucleatum. The red complex (Porphyromonas gingivalis, Tannerella forsythia [formerly Bacteroides forsythus], and Treponema denticola) is comprised of these late colonizers forming a stable, or climax, bacterial community that significantly drive periodontal destruction; the red complex bacteria are putative periodontal pathogens [29]. The subgingival/submarginal microbiota has been found to exhibit significant differences in composition between health and disease [28, 30, 31].
The development of gingivitis has been extensively studied in humans using a controlled paradigm to induce experimental gingivitis [32, 33]. The transition to gingivitis is initiated by inflammatory changes accompanied initially by the appearance of gram‐negative rods and filaments and subsequently by spirochetal and motile microorganisms [34]. The analysis of subgingival/submucosal microbial samples from experimental gingivitis and peri‐implant mucositis has revealed relatively small differences over time, with essentially no differences between gingivitis and peri‐implant mucositis sites [35]. Nonetheless, it has been postulated that a prolonged exposure of implants to the bacterial challenge may yield quantitative and qualitative compositional changes of the inflammatory infiltrate due to the structural and immunologic differences between the gingiva around teeth and the mucosa around titanium implants. These changes include the density of collagen fibers and fibroblasts, collagen fiber orientation, and vascular structure, as well as expression of cell adhesion molecules and inflammatory cell populations [36–38]. Preexisting peri‐implant mucositis, in conjunction with a lack of adherence to maintenance care, has been associated with a higher incidence of peri‐implantitis [11]. Despite the fact that mucositis may be reversible, early diagnosis and appropriate management are clinically important.
Recent studies focused on the precise characterization of microbiome composition associated with periodontitis and peri‐implantitis using 16s rRNA sequencing have shown that red complex pathogens can be found in patients and in periodontal sites in the absence of disease and that other bacterial species, some of which were not necessarily gram‐negative (Filifactor alocis, Peptostreptococcus), appear associated with periodontal and peri‐implant disease [28, 31, 39, 40]. Differences in the composition of the subgingival microbiota between periodontal and peri‐implant diseases are discrete [41–43]. Orange complex microorganisms were more frequent in peri‐implantitis. Porphyromonas gingivalis was the most frequently found red complex organism in peri‐implantitis followed by T. forsythia, P. intermedia, and Prevotella nigrescens [44]. In addition, surface properties of dental implants can influence the adhesion of cells and microbial colonizers and the surface modification limits the effectiveness of mechanical biofilm removal [45]. Although IM is performed as non‐surgical therapy, some degree of surface decontamination, such as use of plastic or metal curettes designed to be used on implant surface, may need to be performed as part of IM [46].
Following active treatment, periodontal and peri‐implant sites are subject to recurrent polymicrobial succession, maturation of a dysbiotic plaque biofilm, and increase in biomass of the microbiota. The rapidity of these changes in microbiota appears dependent on factors such as treatment protocol, the distribution patterns of periodontal microorganisms elsewhere in the oral cavity, and the effectiveness of the patient’s oral hygiene [47]. Bacterial species from the red and orange complex showed a progressive trend toward expansion to pretreatment levels in periodontal sites at 42 days post‐therapy. Two species from the orange complex have also been shown to return to pretreatment levels [48]. Despite the proven overall treatment effectiveness of subgingival biofilm removal, deep periodontal pockets may not revert rapidly or completely to a physiologic sulcus, with shallower probing depths. As a consequence, regular debridement by professional intervention is necessary to prevent recurrence of disease [47].
Prosthesis Design
Prosthesis design influences the risk for biologic complications as it can significantly impact access for oral hygiene care as well as access for effective IM [49, 50]. When the design of a prosthesis limits access to one or more of its surfaces, such as a tissue‐borne bridge or long‐span hybrid restoration with inadequate space for hygiene devices, the maintenance strategy will be more complex. For example, a two‐implant supported three‐unit bridge with ideal interdental distances and adequate space underneath the pontic enables the insertion of interdental brush, whereas a single implant–supported restoration with less than 1.5 mm horizontal distance to adjacent tooth and more than 3 mm height discrepancy (more apical) hampers a patient’s access and ability to effectively clean the implant.
The emergence profile of the prosthesis of the implant/abutment platform must have hygienic contours, and the inter‐implant pontic sections should be reasonably self‐cleansable [51]. The inability to adequately remove microbial biofilm, by the patient or oral health professional, has been associated with the development of peri‐implant disease, thus proper prosthetic design plays an important role [52]. Convex emergence profiles have been found to be a risk factor for peri‐implantitis [53]. Restorations must be contoured to function effectively while protecting and stimulating the gingival tissues. For single‐unit implant restorations, a closed emergence angle (>30°) has been shown to be associated with peri‐implantitis in bone‐level implants but not tissue‐level implants. In natural teeth, using a straight emergence profile in the restoration design has been shown to improve the effectiveness of oral hygiene near the gingival sulcus and facilitates oral hygiene near the gingival sulcus [54]. These design characteristics also hold true for implants [55].
Peri‐implant health and control of inflammatory disease may be influenced by physical access to perform proximal hygiene and by a patient’s mechanical dexterity to perform oral hygiene [56]. Poorer access for proximal hygiene was associated with peri‐implant diseases, especially peri‐implant mucositis. Lack of access to perform proximal hygiene measures was found to be negatively associated to peri‐implant soft tissue conditions. Consequently, peri‐implant disease is associated with greater reported discomfort, pain, and difficulties while performing oral hygiene; moreover, patients generally viewed unfavorably the professional recommendations for oral hygiene care around implants. Importantly, therefore, resolution of peri‐implant mucositis has been documented through modification of the prosthetic contour [57].
Ramfjord and Yuodelis have reported that over‐contouring a prosthesis is a greater hazard to periodontal health than under‐contouring a prosthesis [58, 59]. An over‐contoured implant restoration is a possible a risk indicator of peri‐implantitis. In addition, splinting adjacent implant–supported restorations could be another risk indicator. The prevalence of peri‐implantitis of an implant splinted to both mesial and distal adjacent implants has been found to be 4.6‐fold higher than for a single unit implant restoration [55].
The position of the individual implant should also be considered. Although formation of the biologic width around the dental implant is widely considered a biological phenomenon to create soft tissue seal around the abutment, studies have documented greater peri‐implant probing depth around conventional implants placed subcrestally compared to implants placed at the crest or supra‐crestally [60, 61]. The difference in the height of the platform of the prosthesis might pose difficulty in accessing the interproximal area of the implant [62]. A deeper position of the implant results in a higher crown‐to‐implant ratio and a shallower emergence angle [55]. Implants placed at the subcrestal position displayed greater infra‐osseous defects than those implants placed at the crestal position in a ligature induced peri‐implantitis model in animal model [63].
Another factor associated with higher incidence of peri‐implantitis was encountered in sites where implants were positioned with <3 mm inter‐implant distance. Given adequate interproximal distance, this small distance can often be attributed to clinician error in implant positioning and placement. The design of the splinted restoration or bridge can impair effective oral hygiene; for example, concavities in the internal portion of the restorations must be avoided to reduce plaque accumulation and present mucosal irritation from impaired cleaning. In addition, oral hygiene performance has been shown to be impaired when the prosthesis contacts the mucosa, consistent with patient reports of mucosal irritation due to the lack of space for the use of the devices [64]. Insufficient inter‐implant distance also influences the formation of “black triangle” in the interproximal space which may cause esthetic and functional problems including food impaction [65, 66].
Compared to single‐unit restorations, full‐mouth implant rehabilitations were found to pose a 16‐time greater risk for peri‐implantitis. The latter may be attributed to the difficulty in plaque removal by patients and dental professionals [49]. Full‐arch fixed prosthesis supported by a number of implants, commonly four to six, can be made of a milled metal bar screwed directly onto implant abutments and a resin portion for the replacement of teeth and mucosal tissues [67]. Removal of a fixed, screw‐retained implant prosthesis for evaluation is not needed unless there are signs of peri‐implantitis, a demonstrated inability to maintain adequate oral hygiene, or there are mechanical complications that require removal [68]. However, ineffective oral hygiene around the prosthetic abutments related to difficulties in using oral hygiene devices is a common cause of chronic peri‐implant mucositis and risk of peri‐implantitis. As part of a periodontal maintenance regimen, one should review the plaque index. Comparatively high plaque index scores have been observed on lingual surfaces of full arch restorations, which may be attributable to conformation of the prosthesis and to objective difficulties in reaching those surfaces using only interdental brushes [69]. In instances where prosthetic design hampers access for effective oral hygiene, periodic removal of the prosthesis may be considered (Figure 11.1).
In addition to the prosthetic considerations, other implant‐level modifying factors to consider when designing an IM treatment plan include a lack of (or absence of) supportive keratinized tissue, the presence of deep probing depths, and the presence of foreign bodies such as titanium particles and remaining cement [1470–72]. Furthermore, implants with modified surfaces may warrant special attention, because surface modifications appear to predispose implants to disease progression [73]. A lack of keratinized tissue or a limited zone of keratinized tissue may also predispose implants to disease progression, warranting regular professional maintenance to promote peri‐implant health [14]. If a lack of keratinized tissue or a limited zone of keratinized tissue is associated with pain and/or discomfort for a patient in performing oral hygiene, the clinician should implement a more targeted maintenance plan. Similarly, the exposure of implant threads due to peri‐implantitis or active treatment may increase the risk of disease progression. A shorter maintenance interval is recommended once implant thread exposure is recognized, especially for rough surface implants since effective oral hygiene is difficult to achieve [74]. Even with surgical exposure (e.g. open flap debridement), the mechanical and chemical debridement of rough surface implants is difficult.
Figure 11.1 Mandibular implant‐supported prosthesis design exhibiting poor access to underlying implants and supportive tissues.
When designing an IM maintenance plan, there are multiple considerations to help guide the clinician in establishing an overall maintenance plan, including recall interval. The clinician must assess all host‐level considerations, such as risk factors, systemic health status, compliance, and environmental modifiers, as well as implant‐level considerations, such as prosthesis design, position, access, quality of supportive gingival tissues, and presence of foreign bodies.
Elements of a Implant Maintenance Appointment
PM and IM have a shared goal of controlling disease progression by regular surveillance of periodontal and peri‐implant health status and by reducing the biomass of the bacterial plaque. Thus, a practitioner familiar with the elements of a periodontal maintenance appointment will find little difference with the elements of an IM maintenance appointment as presented below [68]. The dentist must monitor for adverse factors that persist despite treatment and maintenance as well as evaluate new findings that arise during the maintenance session, all of which will have an effect on the future IM regimen and interval (Figure 11.2).
Figure 11.2 The elements of a supportive implant care at the maintenance appointment.
Review of Health Status
At the start of each appointment, it is important to review with the patient changes to systemic health status; this includes but is not limited to updates to medical diagnoses, new or changed medications, surgeries, and procedures since the last visit, as well as updated laboratory results. The name and contact information for the patient’s medical team (primary care manager, specialists, pharmacists, etc.) should also be confirmed. During this portion of the visit, new information that might shorten the maintenance interval include signs of systemic disease decline, such as worsening diabetic control as evident by rising HbA1c levels over 7%, or a new medical diagnosis that could impede a patient’s home care, such as a cognitive or physical impairment. In contrast, if it is determined that the patient has had a considerable improvement in the control of their systemic disease, this may signal an opportunity to lengthen the interval between maintenance visits.
Review of Dental Status
It is equally important to review any changes to the patient’s dental health status. This includes inquiring about visits to other dentists, procedures completed, and pending treatment plans. Likewise, confirm the current recall interval and other practitioners involved in the patient’s dental treatment team – this is especially important in the case the patient splits maintenance appointments between two offices, such as between a general dentist and a periodontist.
Review Radiographs
In line with the review of dental status, the dentist should review radiographs and determine the need for updates to the radiographic record. A general rule for implant health surveillance is to obtain new radiographs yearly after implant loading. A change of greater than 0.5 mm (the radiographic measurement error) indicates a need to act, whether it be to shorten the maintenance interval or to place the patient back into active therapy [15].
Oral Examination
The oral examination is the critical component of the IM maintenance appointment. The examination should include an oral cancer screening exam and the assessment of the color, consistency, and contour of the gingiva. Periodontal and peri‐implant charting should be performed that includes probing depths, clinical attachment levels, mobility of teeth or implants, furcation involvement, assessment of keratinized gingiva/mucosa, presence of plaque and calculus, and bleeding on probing. Additionally, the evaluation includes an assessment of the color, consistency, and contour of the lining or masticatory mucosa at the interface of the implant. Data obtained from the examination that signals a need to shorten maintenance interval or to return the patient to active therapy would be probing depths greater than or equal to 6 mm, increased plaque retention, increased bleeding on probing, and other clinical signs of a worsening status.
Oral Hygiene Assessment
During the examination, the dentist should be assessing the patient’s home care effectiveness and compliance by the presence of plaque and calculus. Attention should be paid to the location of the plaque as a guide to where the patient needs to improve their oral hygiene efficiency. Patients who are struggling with effective home care despite targeted oral hygiene instructions are candidates for shorter maintenance intervals.
Biofilm Removal
Once the examination and assessment portion of the IM appointment is complete, the clinician should complete a full mouth biofilm removal. For areas with no loss of attachment or signs of disease progression, this may be completed with supragingival polish. In areas of deep or advancing probing depths, scaling and root planing of the implant surface is advised. For implant sites it is important to pay special attention to the instrument type used, implant surfaces, and access for biofilm removal. Surface modification of dental implants contributes more bacterial adhesion and biofilm formation compared to natural teeth. This requires mechanical debridement like scaling to eliminate bacteria from the site of inflammation, the use of additional antiseptic treatment to disinfect the implant surface, and the application of antibiotics to remove bacteria in the surrounding peri‐implant tissues [75].
During this portion of the appointment, the dentist should also assess the need for prosthesis removal. As previously mentioned, the American College of Prosthodontists’s position paper states that removal of screw‐retained implant fixed prostheses for evaluation is not needed unless there are signs of peri‐implantitis, a demonstrated inability to maintain adequate oral hygiene, or there are mechanical complications that require removal (Figure 11.3) [51]. The latter guidance is consistent with the management of periodontal disease, when periodic removal of the prosthesis is necessary to perform effective mechanical debridement and root planing. The periodic removal of the prosthesis should also be performed to facilitate IM, although removal may not be indicated at every maintenance visit.
Figure 11.3 Implant‐supported prothesis with biofilm build‐up despite design allowing for home care.
Source: Courtesy of Keith Merchant, DDS, MS and David Bell DDS, MS.
Methods for Biofilm Removal During Implant Maintenance
The removal of supra‐ and subgingival biofilm deposits is a critical component of professional maintenance visits, with recall intervals determined by multiple clinical considerations, including risk factors. Disruption of the biofilms is most commonly achieved by mechanical intervention. In implant sites that exhibit no inflammation and are in peri‐implant health, treatment should be limited to coronal polishing. Subgingival instrumentation is generally indicated at implant sites exhibiting bacterial deposits, mucosal inflammation, or signs of peri‐implantitis.
Mechanical Methods
A broad selection of mechanical instruments is available for use in the non‐surgical maintenance of implants at risk for disease progression. This list of instruments includes curettes, scalers, and modified piezoelectric or ultrasonic tips. It is widely considered a best practice to employ instruments that are manufactured expressly for use against an implant surface composed of materials that minimize the risk of damaging the implant surface, such as plastics, graphite, or titanium. Unintentional modifications of the implant surface can hamper plaque control and, thereby, increase risk of disease progression [6]. Additional instruments available for the mechanical debridement of implant surfaces include titanium brushes, lasers, and glycine air‐abrasives [76]. However, these options may not be practical considering maintenance therapy is conducted in a closed‐scaling environment [77, 78].
Chemical Adjuncts
A variety of chemical agents can be used to aid in biofilm removal during IM, including chlorhexidine, ethylenediaminetetraacetic acid (EDTA), povidone‐iodine, and hydrogen peroxide [76, 77, 79]. The clinician can also consider the use of a locally delivered antibiotic. In a six‐month study of a maintenance program for implants following surgical treatment of peri‐implantitis, topically applied minocycline gel improved clinical and radiographic parameters [80]. A recent multicenter randomized study conducted by Machtei et al. showed the efficacy of a Chlorhexidine‐containing slow‐release device (PerioChip) in terms of pocket reduction and clinical attachment gain when used as an adjunct to biweekly supragingival debridement for 12 weeks as compared to supragingival debridement alone [81]. Emerging evidence on the local administration of antimicrobials for the treatment of peri‐implant disease is encouraging; however, no commercially available antimicrobials in the United States have received regulatory approval for the treatment of peri‐implant diseases. Clinicians should exercise careful professional judgment in the off‐market clinical application of antimicrobial agents or compounds.
Miscellaneous Adjuncts
To improve access and ease of biofilm removal during IM appointments, the dentist might consider the adjunctive application of lasers (Nd:Yag, Er:YAG, Er,Cr:YSGG, Diodes) to boost disinfection and endoscopes to improve visualization of calculus and other foreign objects [18, 78, 82]. However, long‐term outcomes have not been well‐established following laser therapy during regular maintenance care for the treatment of peri‐implant disease [83].
Oral Hygiene Instruction
Upon completion of biofilm removal, the patient should be instructed on appropriate, customized oral hygiene instructions. Emphasis should be placed on oral hygiene techniques and specific implant sites that would benefit from improvement. A toothbrush and dental floss remain the most widely recommended oral hygiene devices for patients. Many patients will have a need for additional hygiene adjuncts, such as floss threaders, specialized stiff‐ended floss, interdental brushes, end‐tufted brushes, sulcular brushes, and irrigating devices. The need for these adjunct devices will depend on the patient’s dexterity, location of troubled areas, and the impact the prosthesis has on patient access.
Assess the Effectiveness of the Current Maintenance Plan
Intricately linked to all the elements and steps of a maintenance appointment is evaluation of the effectiveness of the maintenance recall interval. As stated throughout this chapter, in addition to evidence of poor oral hygiene effectiveness or compliance, other factors such as systemic disease status and evidence of disease progression will shorten or lengthen the recall interval. The next section will discuss specific guidelines about setting maintenance intervals.
Interval and Considerations
Clinicians often recommend an initial maintenance interval of three months for patients with a history of periodontitis. However, the appropriate maintenance interval is not the same for all patients. A five‐year follow‐up study demonstrated the importance of IM to prevent peri‐implant mucositis progressing to peri‐implantitis [11]. The prevalence of peri‐implantitis (PD ≥ 5 mm, bleeding on probing and/or suppuration, and bone loss) was found to be higher among patients not in professional maintenance care (43.9%) compared to those receiving regular supportive care (18%). Longitudinal clinical results from treated and maintained populations, as well as data from randomized controlled clinical trials, show that supportive periodontal care at three‐ to four‐month intervals is sufficient to control disease in most patients [6, 7, 84, 85]. However, shorter or longer maintenance intervals may be appropriate depending on risk assessment. The clinician must customize the professional maintenance interval to the patient, with the goal of achieving long‐term outcomes in peri‐implant health.
Host‐level Considerations
The evidence from periodontal literature suggests that, in general, patients previously treated for chronic periodontitis and/or peri‐implantitis appear to require more frequent periodontal maintenance. An increase in susceptibility to peri‐implantitis also has been reported in individuals with a history of periodontitis [10]. A relatively short maintenance interval of three to four months is based, in part, on the risk for disease progression. A recent five‐year prospective study assessing the risk for recurrence/progression of peri‐implantitis following surgical therapy showed 44% of implants displayed recurrence/progression of disease during the follow‐up period [73]. In addition, longitudinal clinical results from treated‐and‐maintained populations, and data from randomized controlled clinical trials, show that supportive periodontal care at three‐ to four‐month intervals is effective in controlling disease progression in most persons [6, 7, 84, 85].
Additional host‐level considerations that may guide the recommendation to shorten the maintenance interval include systemic considerations, such as uncontrolled diabetes, smoking, and head and neck radiation [6,14–16, 20, 86], as well as patient age and loss of cognitive or physical function impacting home care [18]. Patient compliance with home care instructions or effectiveness in oral hygiene should be considered in developing a maintenance program. Changes in host‐level factors, such as glycemic control or radiation therapy, must be considered in determining the interval of IM [16, 87].
Implant‐level Considerations
As we have discussed above, complexity in the biofilm removal and prosthetics design as well as other implant‐level factors, such as a lack of keratinized tissue, the presence of exposed or modified implant threads, as well as clinical signs of unstable parameters like residual probing depths greater than 5 mm and unresolved inflammation, can be used to set the baseline for the MI interval [6].
The decision algorithm can be considered a two‐step process.
First, determine whether either (i) the prosthesis impedes the patient’s access to perform home care or (ii) if the residual probing depth(s) limits the professional care. Second, determine whether systemic factors, such as diabetes, neurologic or musculoskeletal diseases, or local/implant‐level factors, such as pontic design or a lack of keratinized gingiva are present and their subsequent impact on maintenance success. The final recommendation must be informed by consideration of all relevant local and systemic factors. In certain instances, the presence of one factor (such as need of periodical removal of the prosthesis) may drive the decision.
When a Return to Active Therapy is Warranted
The purpose of IM is to maintain peri‐implant health as well as to recognize the development and progression of peri‐implantitis; clinical findings may present early during follow‐up indicating a return to a diseased state of peri‐implantitis. In addition, untreated peri‐implantitis appears to progress in a non‐linear, accelerating pattern, and at a faster rate than observed in periodontitis [8]. Persistent residual probing depths ≥6 mm is a predictor for additional bone loss in patients diagnosed with peri‐implantitis [73]. For this reason, a radiographic exam should be completed to evaluate bone levels for evidence of new loss. If a pattern of continuous bone loss is established, a problem‐focused procedure such as local debridement should be performed at the time of IM. The latter also holds true with the return of other clinical signs such as thread exposure, bleeding and suppuration on probing, swelling of the peri‐implant soft tissues, and symptoms of pain and discomfort. After completion of focused treatment and re‐evaluation, the clinician should consider initiating a new round of active implant therapy.
Applying These Guidelines to Three Clinical Scenarios
VIDEdental - Online dental courses
