Deborah M. Lyle, MS, BS, RDH
There is no standard of care for implant maintenance. The evidence is either non-existent or insufficient. Now, you may ask: “What do we recommend to our patients?” For single implants that have a conventional crown it may be as simple as doing whatever is done with natural teeth (Figure 1). However, this is not always the case. Many implants may have an atypical crown design that requires a different approach (Figure 2). Denture retained implants add another challenge to the regimen, especially if they cannot be removed (Figure 3).
What we need is evidence that is measurable and predictable on how to maintain implants with different prosthesis. There are two parts to the success and longevity of dental implants: regular assessment and debridement by the dental team and daily personal oral hygiene methods.1-3 The patient needs to understand that once the implant is placed and the prosthetic is completed they are responsible for the daily cleaning of their mouth. They rely on dental professionals to tell them how to do this.
Systematic reviews show that professional periodic maintenance therapy for the prevention of peri-implant mucositis and peri-implantitis is effective.1-3 It is also reported that an interval of 5 to 6 months provided positive outcomes, but ideally it is best to customize depending on the patients risk profile.1
Dental Implant Self-Care
Just like natural teeth, the biofilm needs to be removed or disturbed on a daily basis to prevent infection. Keep in mind that healthy peri-implant mucosal tissue may be 3 – 4 mm high post healing, although it can be deeper in some individuals.4
Tooth brushing is the mainstay of oral hygiene. A manual toothbrush is very effective in removing biofilm when used correctly and an electric toothbrush may provide an added benefit. There is limited research when it comes to using an electric toothbrush with implants. Overall, either an oscillating-rotating or sonic toothbrush was no better than a manual toothbrush. They are safe to use and may increase compliance.5-10
String floss may work fine depending on the size and shape of the single implant prosthesis. This is anecdotal and care must be taken to monitor the mucosal tissue and probing depths. Case studies have reported that tufted floss caused peri-implant mucositis and peri-implantitis. Ten cases of patients in an intensive maintenance program, who were adhering to oral hygiene recommendations, had unresolved mucositis and radiographic bone loss. Exploratory surgery revealed remnants of the tufted floss were wrapped around the rough part of the implant. After removal complete resolution was seen in 9 out of 10 cases. One case showed pocket depth reduction but still had bleeding on probing.11
A case report with a 6-year follow-up had a similar outcome. A 66 year-old man reported chronic pain, recurrent swelling and spontaneous bleeding. Peri-implant mucocistis was evident clinically and peri-implantitis was revealed on the radiographs. Probing of the area was impeded and exploration with a perioscope showed filament foreign body which turned out to be remnants of the tufted floss. The fibers were removed, resolution was seen in 10 days and the patient was still stable at the 6-year follow-up.12
The hydrodynamic shear forces of pulsating water allow access around the implant interface and the prosthesis where other devices cannot reach. This is a promising, easy and logical way to clean implants (Figure 4).
There is limited data, but in this case the water flosser was compared to brushing and flossing with single implants and was twice as effective for reducing bleeding and preferred by the patients.13 Water flossing was also compared to the CIOTIPlus systematic brushing sequence, (chewing, inside, outside), followed by tongue cleaning and interdental cleaning with dental floss or interdental brushes. The water flossing group showed a significantly better reduction in mucositis severity score compared to the CIOTIPlus group.14
A new tip designed to direct the water under an implant retain denture was introduced to the market for use with a Waterpik® Water Flosser (Figure 5). The tip is used from the lingual area and directed under the denture.
Anecdotally, interdental brushes may be effective if they can fit into the interdental space and contour under the prosthetic when needed. This was shown in a study where 54% of the prostheses prevented access for proper interdental cleaning and led to a higher prevalence of peri-implant disease.15
The absence of data to guide self-care recommendations is lacking to say the least. What we do know is that electric toothbrushes are safe to use and if preferred by the patient, may increase adherence. A water flosser may be the best answer as the hydrodynamic shear forces of pulsating water allows access in small and hard to reach areas. It is also quick and easy to use.
More research and innovation is needed as the incidence of peri-implant mucositis and peri-implantitis will continue to be a problem if patients cannot maintain an adequate oral hygiene regimen.
- Monje A, Aranda L, Diaz KT et al. Impact of maintenance therapy for the preventions of peri-implant diseases: a systematic review and meta-analysis. J Dent Res 2016; 95(4):372-379.
- Roccuzzo M, Layton DM, Roccuzzo A, Heitz-Mayfield LJ. Clinical outcomes of peri-implantitis treatment and supportive care: A systematic review. Clin Oral Impl Res 2018; 29(Suppl 16):331-350.
- Jepsen S, Berglundh T, Genco R et al. Primary prevention of peri-implantitis: managing peri-implant mucositis. J Clin Periodontol 2015: 42(Suppl 16):S152-S157.
- Araujo MG, Lindhe J. Peri-implant health. J Clin Periodontol 2018; 45(Suppl 20):S230-S236.
- Allocca G, Pudylyk D, Signorino F, Grossi GB, Maiorana C. Effectiveness and compliance fo an oscillating-rotating toothbrush in patients with dental implants: a randomized clinical trial. Int J Impl Dent 2018; https//doi.org10.1186/s40729-018-0150-6.
- Vandekerckhove B, Wuirynen M, Warren PR, Strate J, van Steenberghe D. The safety and efficacy of a powered toothbrush on soft tissues in patients with implant-supported fixed prostheses. Clin Oral Invest 2004; 8:206-210.
- Rasperini G, Pellefrini G, Cortella A et al. The safety and acceptability of an electric toothbrush on peri-implant mucosa in patients with oral implants in aesthetic areas: a prospective cohort study. Eur J Oral Implantol 2008;1(3):221-228.
- Lee J, Lim JH, Lee J et al. Efficacy of sonic-powered toothbrushes for plaque removal in patients with peri-implant mucositis. J Periodontol Impl Sci 2015;45:56-61.
- Swierkot K, Brusius M, Leismann D et al. Manual versus sonic-powered toothbrushing for plaque reduction in patients with dental implants: an explanatory randomized controlled trial. Eur J Oral Implantol 2013;6(2):133-144.
- Wolff L, Kim A, Nunn M, Bakdash B, Hinrichs J. Effectiveness of a sonic toothbrush in maintenance of dental implants. A prospective study. J Clin Periodontol 1998;25(10):821-828.
- Van Velzen FJJ, Lang NP, Schulten EAJM, Ten Bruggenkate CM. Dental foss as a possible risk for the development of peri-implant disease: an observational study of 10 cases. Clin Oral Impl Res 2015;00:1-5.
- Montevecchi M, De Blasi V, Checchi L. Is implant flossing a risk-free procedure? A case report with a 6-year follow-up. Int J Oral Maxillofac Impl 2016;31:e790-e83.
- Magnuson B, Harsono M, Stark PC, Lyle D, Kugel G, Perry R. Comparison of the effect of two interdental cleaning devices around implants on the reduction of bleeding: A 30-day randomized clinical trial. Compend of Contin Ed in Dent 2013; 34(Special Issue 8):2-7.
- Bunk D, Eisenburger M, Häckl S, Eberhard J, Stiesch M, Grischke J. The effect of adjuvant oral irrigation on self-administered oral care in the management of peri-implant mucositis: a randomized controlled clinical trial. Clin Oral Impl Res 2020;00:1-13. DOI: 10.1111/clr.13638.
- Chongcharoen N, Lulic M, Lang NP. Effectiveness of different interdental brushes on cleaning the interproximal surfaces of teeth and implants: a randomized controlled, double-blind cross-over study. Clin Oral Impl Res 2011;23:635-640.