Michelle Strange, MSDH, has been a clinician in dentistry since 2000 and currently is a practicing hygienist, surgical assistant, speaker, volunteer, educator in a dental hygiene program, lead clinical educator for TePe Oral Health Care, Inc., and podcast co-host of “A Tale of Two Hygienists." She is a self-proclaimed dental nerd and sees the dental profession as not only her forever career path but her hobby. With a master’s degree in dental hygiene education and a belief in life-long learning, Michelle hopes to continue to learn and grow within the dental profession and one day see the gap bridged between medical and dental. Her experience as a hygienist began in a periodontal- and implant-driven office where she gained much experience with the maintenance of dental implants. Her passion is helping patients be successful at home with a goal of better oral health with a patient-centered approach.

Michelle Strange

	Dental hygiene school is no joke. Students spend countless hours understanding tooth morphology, calculus detection and removal around said morphology. The understanding of healing and recreating a healthy attachment level, knowing what health looks like and what to do when disease has taken hold of a person’s mouth is coached into the minds of students to the point they may even chant it in their sleep.

	However, if we look at what we know of natural teeth versus dental implants, not every hygienist will feel as comfortable in his or her knowledge base. Every week there is a new Facebook post about dental implants. We are all comfortable with seeing patients who have natural teeth in their mouths, but not all hygienists are comfortable with handling dental implants. Now that dental implant placement is growing and becoming a part of everyday dentistry, it is time we ALL get comfortable with dental implants. Sticking your head in the sand like you don’t see it or just pretending it is like a natural tooth isn’t going to cut it.

	Here are five things to consider the next time you see a dental implant.

	It is confusing as to why, in 2017, probing dental implants is still a controversial topic with little consistency in the proper protocol. Let’s be clear, evidence-based dentistry supports proper probing technique as a way to monitor the health of dental implants.

 Probing around dental implants not only gives you quantitative information like the depth of the sulcus, but it also allows for qualitative information like tissue health and gingival consistency.

Keeping in mind that a 5 mm probing depth doesn’t necessarily mean that we need to shove the patient out of the chair and refer him or her out because there are signs of disease. Implant probing depths can range depending on how they were placed.

It is important to have a baseline probing depth after the implant has been restored so there is always something to compare the current measurements to. With that said, hygienists must keep in mind that 5 mm measurements around implants might not mean disease activity, but these are areas that could harbor higher levels of anaerobic bacteria, so timely professional maintenance and at-home care will be important! 

	“Yeah, but, my doctor says not to probe around the implant because we can break that seal and cause trauma.”  So, let’s talk about that! 

	There is no arguing that the attachment around an implant is different, with only a few types of fibers creating more of a rubber band effect around the implant and never attaching to the implant itself. This is a more fragile environment compared to a natural tooth and does require a more gentle probing technique. 

 This, however, does not negate the need to probe around dental implants. Studies clearly show that with gentle insertion of the probe, metal or plastic, does not damage the mucosal attachment. 

 In the case of inflammation around a dental implant, the chance that the probe will penetrate the attachment level has shown to be higher. The argument then is that this is in the presence of inflammation, and NOT probing could miss these signs of inflammation, creating a higher chance of progressing and far more problems than any trauma from probing. Not to mention, if a probe is inserted too forcefully, it can heal. Hygienists were taught how to properly probe around natural teeth; we are smart enough to figure this out too!

	At the end of the day, not probing is supervised neglect.

 We have to monitor implants properly and probing is a part of that assessment process. 

	Now that we got the to probe or not to probe discussion out of the way, we can talk about the other assessment procedures hygienists should be doing, in addition to probing. In Susan Wingrove’s book for implant maintenance, she breaks down implant assessment into five categories: visual assessment, probing and palpation, identifying calculus with a lasso flossing technique, evaluation of mobility, and radiographic evaluation.

 In addition to that, tapping (creating percussion) on the implant crown for signs of pain, checking the occlusion and checking for good contacts are important as well.

 Many clinicians have, in fact, discovered suppuration on palpation, but never on probing. This is why, again, probing is just a portion of the picture. Making sure that the crown or implant doesn’t have mobility, ensuring that cement or calucus isn’t present as an irritant, and ensuring the occlusal forces are not too heavy are what help hygienists and dentists to see the overall health and stability of an implant.

	Defining the health status of an implant is a bit muddy. When reading studies, there are many that will have a slightly different definition of what healthy is, what peri-implant mucositis is, what peri-implantitits is, and now we have a new term, cementitis. Making sure we are all comparing apples to apples is important. Safely, we can define health around an implant as “homeostasis between the peri-implant tissues and the microbial communities that have colonized the device.”

	Similar to the disease process around natural teeth-gingivitis and periodontitis-dental implants can develop peri-implant mucositis and peri-implantitis.  It is beneficial to keep bacterial reservoirs like the ones in the mouth at the lowest levels possible in order to reduce chances of the development of disease. When this doesn’t transpire, dysbiosis can occur. This will be characterized by bleeding, redness and a more spongy consistency in the tissue, and is termed mucositis. At this point, there is no bone loss outside of the original remodeling process after initial loading, and exudate is not usually present. 

	This is the stage where hygienists can be the heroes! With proper professional maintenance and creating a suitable and realistic at-home routine, this stage of disease can be reversed. If this is accomplished, the disease progression can be arrested, preventing the next stage, which is peri-implantitis.

	Peri-implantitis is similar to periodontitis, in that now there is bone loss around the implant in addition to bleeding and possibly exudate. 

 Preventing this stage is becoming more and more important because once peri-implantitis occurs, there is not a reliable and predictable way to treat the issue. 

	Now we have a new term, cementitis, which is peri-implantitis caused by residual cement left behind at sub-mucosal sites after cementation of implant crowns. 

 Unfortunately, this is something that can be an issue immediately after placement of the implant crown, but also, many years down the road as the body develops a foreign body response to the cement. 

 This is a great argument for why it is so important to constantly and consistently assess dental implants as issues can arise from what seems like nowhere after the implant has been healthy for many years.	 

	Unfortunately, implant definitions vary and doctors, surgeons and even implant companies can have a variety of names for implant components. If we can simplify it for the sake of this article, the various structures involved typically are: the crown or implant prosthesis, the abutment that typically has a polished collar, and the implant body that now more often has a roughened, etched surface.

	When we have that patient in the chair with dental implants, before we pick up an instrument, we need to ask ourselves: What does this implant need?  The answer might be simply biofilm removal and not with a scaler. If a dental implant is healthy and biofilm is all that needs to be managed, a scaler isn’t the best option. Rubber cup polishing with a non-abrasive paste, the lassoing technique with floss or air polishing with glycine powder have all shown to disrupt more biofilm than scalers without altering any crown or implant surfaces.

 Not to mention, around a healthy implant with tight tissue attachment, scalers are not easy to insert in that peri-implant sulcus.   

	If any portion of the abutment is exposed, typically this is a smooth, polished surface, and hygienists need to be mindful of creating surface alternations. Often you will hear, “Just use your normal stainless steel instruments.” When we look at the research surrounding the proper protocol for implant maintenance and scalers, there are conflicting opinions. At the end of the day, studies clearly show that implants have the most surface alterations with stainless steel instruments. 

 Not to mention, we aren’t just worried about gouging or scratches but also surface alternations that affect biocompatibility. Studies have brought up the concern that stainless steel can leave behind metal ions and cause galvanic reactions, making the titanium surface more susceptible to bacterial plaque.

 Surface alterations are of special interest when there is the possibility of future regenerative procedures, and using the instruments that are really meant for natural teeth could interfere with future procedures.

	Some would argue that there isn’t enough research to show that stainless steel will be an issue, and I would argue that there isn’t enough research to show that it won’t be an issue. At the end of the day, stainless steel instruments were meant for natural teeth. Using instruments that have a better biocapability level like medical grade titanium would be a more appropriate choice. If removing calculus, titanium instruments would be sufficient since calculus is usually softer and easy to remove around implant structures. If there is no presence of cement or calculus to be removed, scalers have not shown to remove the sticky biofilm layer, and use of the glycine powder or the other ways of disrupting biofilm would be more advantageous anyway. 

	5. How is the patient going to clean it?

	What is done in-office for implant maintenance is important, but arguably, what happens at home is the most important. Hopefully, the patient was vetted before the placement of dental implants and he or she is aware of his or her level of responsibility in the new prosthetic’s long-term success. 

 Most people are edentulous for a reason, and placing implants when the patient wasn’t able to maintain his or her natural teeth successfully makes his or her long-term success more difficult. Ronay, et al., reminds clinicians that “the formation of biofilm on the implant surface plays a major etiological role” in the development of peri-implantitis.

 Making sure patients can manage biofilm at home will be crucial. Ensuring that clinicians are recommending products that are not only right for the patient’s implant type and prosthetic design but also for his or her level of motivation, dexterity and lifestyle. It isn’t a one-size-fits-all approach when we are recommending home care. Saying that oral irrigation or floss or an electric toothbrush is what is needed for every patient is just wrong. Having conversations with patients about what worked for them when maintaining their natural teeth and seeing if that would apply to their dental implant care is a good first step. Explaining that dental implants are different than natural teeth and require more attention is a crucial conversation to have with the patient. Recommending products that would be best for their implant case and then demonstrating it, ensuring they are able to do this at home without fuss, is the key to at-home success. It is the clinician’s duty to help the patient find the best products for each patient’s dental implants. They should not be allowed to “wing it” and hope for the best. We need to help ensure patients don’t ignore their new dental implant because, even though it won’t decay, they can still lose it.

	Helping patients find the products that are right for their implant cases is inarguably the most important step in implant maintenance.

	For years, surgeons, restorative dentists, speakers, researchers and writers have been discussing the proper placement procedures, implant systems, CBCT hardware, restorative material, etc., but at the end of the day, implant maintenance, or lack thereof, can make or break a dental implant’s success. Dental hygienists need to grab the reigns and delve into implant maintenance as we did during dental hygiene school when learning about natural teeth. We should question, research and stay abreast of the new techniques and tools. It is our duty as clinicians to not put our heads in the sand or listen to speakers just because they are on the podium and claim to be the expert. It is our duty to make sure that we are the professionals in implant maintenance as we claim to be with natural teeth. Be sure to do your due diligence for the sake of your patients and their dental implants.

	1. Fakhravar B, Khocht A, Jefferies SR, Suzuki JB. Probing and scaling instrumentation on implant abutment surfaces: an in vitro study. 

	2. Armitage GC, Xenoudi P. Post-treatment supportive care for the natural dentition and dental implants. 

	4. Gulati M, Govila V, Anand V, Anand B. Implant Maintenance: A Clinical Update. 

Peri-implant therapy for the dental hygienist: clinical guide to maintenance and disease complications

	6. De Bruyn H, Christiaens V, Doornewaard R, Jacobsson M, Cosyn J, Jacquet W, Vervaeke S. Implant surface roughness and patient factors on long-term peri-implant bone loss. 

	7. Schmage P, Kahili F, Nergiz I, Scorziello TM, Platzer U, Pfeiffer P. Cleaning effectiveness of implant prophylaxis instruments. 

	8. Ronay V, Merlini A, Attin T, Schmidlin PR, Sahrmann P. In vitro cleaning potential of three implant debridement methods. Simulation of the non-surgical approach. 

	9. Lupi S, Granati M, Butera A, Collesano V, Baena RY. Air-abrasive debridement with glycine powder versus manual debridement and chlorhexidine administration for the maintenance of peri-implant health status: a six-month randomized clinical trial. 

	10. Hasturk H, Nguyen DH, Sherzai H, Song X, Soukos N, Bidlack FB, Van Dyke TE. Comparison of the impact of scaler material composition on polished titanium implant abutment surfaces. 

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