C H A P T E R 8 6
Jonathan H. Do, Perry R. Klokkevold
Rationale for Supportive Implant Treatment
Examination of Implants
Assessment of Peri-implant Health
Treatment of Peri-implant Diseases
Referral of Patients to the Periodontist
Dental implant therapy does not end with the final prosthetic
restoration of the implant. Predictability and long-term success of a
dental implant and its restoration require sound treatment
planning, precise surgical and restorative execution, and
impeccable long-term maintenance, which depend on patient
compliance with home care and professional supportive implant
Peri-implant maintenance begins as the implant becomes exposed
to the oral cavity and continues at regular intervals during the life
of the implant. The recall interval is determined by the patient's oral
hygiene and susceptibility to biofilm-induced inflammatory
diseases. For the first year after treatment, recall maintenance visits
should be scheduled at 3-month intervals and then adjusted to suit
the patient's needs. Patients who have good oral hygiene, minimal
deposits, and disease resistance require infrequent professional
hygiene maintenance, whereas those who have poor oral hygiene,
heavy deposits, and disease susceptibility require more frequent
Rationale for Supportive Implant
Although dental implants are not vulnerable to dental caries, they
are susceptible to mechanical complications and peri-implant,
biofilm-induced inflammatory tissue changes. A 10-year
of 397 fixed-implant reconstructions in 300
patients observed a mechanical complication rate of 24.7%. The
most frequent complication was ceramic chipping (20.31%),
followed by occlusal screw loosening (2.57%) and loss of retention
(2.06%). Although relatively infrequent, occlusal screw loosening
can result in a subgingival gap at the implant–abutment junction
that retains plaque and stimulates an inflammatory reaction in soft
and hard tissues.
Biologically, biofilm accumulation due to inadequate or no access
for oral hygiene can result in peri-implant mucositis and peri-
implantitis. Peri-implant mucositis is characterized by
inflammation confined to the soft tissue and is reported to affect up
to 80% of patients with dental implants.
characterized by peri-implant inflammation with progressive
crestal bone loss beyond the initial remodeling. The prevalence of
peri-implantitis among patients is 11.2% to 53%.
hygiene, residual cement, current or history of periodontitis,
cigarette smoking, and diabetes mellitus are risk factors for peri-
The relationship between peri-implant mucositis and peri-
implantitis is similar to that between gingivitis and periodontitis.
Although peri-implant mucositis does not necessarily progress to
peri-implantitis, it is likely the precursor to peri-implantitis.
inflammatory response in peri-implant disease appears to be
similar to that in periodontal disease.
However, the severity and
rate of disease progression appear to be more pronounced around
implants. This may be caused by the absence of a self-limiting
process, which is observed in periodontitis, around implants that
separates the inflammatory cell infiltrate from the bone.
Experimental models demonstrated that peri-implant mucositis
was reversible at the biomarker level (i.e., matrix metalloproteinase
8 [MMP-8] and interleukin-1β [IL-1β]).
A review of the literature
reported that peri-implant mucositis
could be effectively treated with nonsurgical mechanical therapies,
but these modalities tended to be ineffective against peri-
implantitis. Results of surgical treatment for peri-implantitis are not
predictable. Prevention, early detection, and early treatment of peri-
implant diseases are therefore crucial. Periodic and well-
regimented supportive implant treatment is essential to the long-
term success of dental implant therapy.
Implants are susceptible to mechanical complications and biofilm-
induced inflammatory diseases, such as peri-implant mucositis and
Examination of Implants
The supportive implant treatment appointment should include: an
inquiry about new concerns, problems, or pain; review of changes
in the patient's medical and oral status; evaluation and
reinforcement of oral hygiene; examination and evaluation of soft
and hard tissue health; evaluation of implants and the associated
implant restorations' stability and integrity; and professional
supportive treatment. Assessment should determine the
appropriate recall interval and plan for the next visit.
Examination begins with visual inspection for biofilm and
calculus accumulation; signs of inflammation and swelling; peri-
implant soft tissue quality, color, consistency, and contour; and
aberrations in the implant prosthesis. Peri-implant soft tissue can be
digitally palpated to detect edema, tenderness, exudation, or
suppuration. Peri-implant probing can be done to assess the
condition and level of soft and hard tissues surrounding implants.
When indicated, radiographic images can be obtained to help verify
the level of the peri-implant crestal bone. Determination of implant
stability or mobility and percussion testing can help verify implant
osseointegration (Fig. 86.1).
FIG. 86.1 Peri-implantitis. (A and B) Minimal biofilm accumulation is
seen. The peri-implant mucosa exhibits minimal erythema and edema.
Notice the buccal placement of the implant in B. (C) Manipulation of
tissue indicates a lack of buccal keratinized attached gingiva and
exudation from the peri-implant sulcus (arrow). (D) The periapical
radiograph shows peri-implant bone loss to the apex of the implant.
Implant examination includes evaluation of biofilm control, visual
and tactile assessment of peri-implant tissue for inflammatory
changes and changes in probing depths, and radiographic
examination of the mesial and distal bone level.
Probing of implants can be done with light force (i.e., 0.25 N) using
a traditional steel probe without adverse effects to the peri-implant
Implant probing should be recorded at the time of final
restoration as the baseline measurement and done at least annually
Clinicians should use caution when evaluating peri-implant
probing because these measures cannot be interpreted the same as
probing depths around teeth. Although periodontal probing
around natural teeth is useful for assessing the health of
periodontal tissues, the sulcus or pocket depth, and the level of
attachment, probing around implants may not provide comparable
Due to distinct differences in the tissues that surround and
support teeth compared with those that surround and support
implants, the probe inserts and penetrates differently. Around
teeth, the periodontal probe is resisted by the health of the
periodontal tissues and importantly by the insertion of supracrestal
connective tissue fibers into the cementum of the root surface.
These fibers, which are unique to teeth, are the primary source of
resistance to the probe.
There is no equivalent fiber attachment
around implants. Connective tissue fibers around implants usually
run parallel to the implant or restorative surface and do not have
perpendicular or inserting fibers (see Chapter 74). The primary
source of resistance to the probe depends on the conditions around
At noninflamed sites, the most coronal aspect of
connective tissue adhesion to the implant resists the probe. At
inflamed sites, the probe tip consistently penetrates farther into the
connective tissue until less inflamed connective tissue is
encountered, which is often close to or at the level of bone.
The value of peri-implant probing is different from periodontal
probing and offers comparatively limited information. Probing
around implants can measure the level of the mucosal margin
relative to a fixed position on the implant or restoration and can
also measure the depth of tissue around the implant. The peri-
implant probing depth is often a measure of the thickness of the
surrounding connective tissues and correlates most consistently
with the level of surrounding bone. However, peri-implant probing
is affected by several conditions, including the size of the probe, the
force and direction of insertion, the health and resistance of peri-
implant tissues, the level of bone support, and the features of the
implant, abutment, and prosthesis design (Fig. 86.2).
FIG. 86.2 Buccal probing of the implant is impeded by
the implant restoration.
of probing pocket depth of implants with peri-
implantitis before and after the removal of the prosthetic
restorations reported similar probing depths in only 37% of sites. In
39% of sites, the difference was ±1 mm; in 15% of sites, it was ±2
mm; and in 9% of sites, it was ±3 mm. Probing measurements can
be an accurate measure of soft tissue thickness around an implant
(i.e., peri-implant soft tissue above the bone level), but in many
cases or sites, the inability to properly angle and direct the probe
along the implant can lead to inaccurate assessment of soft tissue
thickness. In these situations, the clinician must appreciate the
limitations and know that other clinical parameters and
radiographs are required to help evaluate the peri-implant's
Probing around implants is likely to vary more than around
teeth. Studies have shown that a change in probing force around
implants results in more dramatic changes than a similar change in
probing force around teeth.
The probing depth around implants
presumed to be healthy (and without bleeding) has been
documented as about 3 mm around all surfaces.
The absence of
bleeding on probing around teeth has been established as an
indicator of health and a predictor of periodontal stability.
comparing bleeding on probing around teeth and implants in the
same patient have reported that bleeding around implants occurs
Bleeding on probing at implant sites can indicate inflammation in
the peri-implant mucosa. However, the ability to use bleeding on
probing as an indicator for assessing diseased or healthy sites
around implants has not been established. Due to the potential for
false-positive bleeding (i.e., provoked bleeding) with probing, the
use of marginal bleeding, which is a more sensitive indicator of
inflammation and is less likely to elicit false-positive bleeding, has
been proposed to assess peri-implant inflammation.
bleeding can be evaluated by running a probe circumferentially
along the coronal portion in the implant sulcus. Overall, the value
of peri-implant probing is in monitoring changes in the probing
pocket depth over time rather than the initial value because some
implants are placed apically for aesthetics.
Probing of implants can be accomplished with a traditional steel
probe. It is valuable for detecting tactilely inflammatory changes in
the tissue, such as loss of tissue to resistance to probe penetration,
sponginess of peri-implant mucosa, and bleeding on probing, and
for monitoring changes in probing depth over time.
Studies in animals and humans have demonstrated the
development of peri-implant mucosal inflammation in response to
the accumulation of bacterial plaque.
suggest that greater probing depths (i.e., pockets) around implants
harbor higher levels of pathogenic microorganisms.
have also documented similarities in the microbial composition of
plaque in healthy periodontal sites compared with healthy peri-
Evidence indicates that the microbiota of diseased
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C H A P T E R 8 6Supportive ImplantTreatmentJonathan H. Do, Perry R. KlokkevoldCHAPTER OUTLINERationale for Supportive Implant TreatmentExamination of ImplantsAssessment of Peri-implant HealthImplant MaintenanceTreatment of Peri-implant DiseasesReferral of Patients to the PeriodontistDental implant therapy does not end with the final prostheticrestoration of the implant. Predictability and long-term success of adental implant and its restoration require sound treatmentplanning, precise surgical and restorative execution, andimpeccable long-term maintenance, which depend on patientcompliance with home care and professional supportive implanttreatment.Peri-implant maintenance begins as the implant becomes exposed4592 to the oral cavity and continues at regular intervals during the lifeof the implant. The recall interval is determined by the patient's oralhygiene and susceptibility to biofilm-induced inflammatorydiseases. For the first year after treatment, recall maintenance visitsshould be scheduled at 3-month intervals and then adjusted to suitthe patient's needs. Patients who have good oral hygiene, minimaldeposits, and disease resistance require infrequent professionalhygiene maintenance, whereas those who have poor oral hygiene,heavy deposits, and disease susceptibility require more frequentfollow-up care.Rationale for Supportive ImplantTreatmentAlthough dental implants are not vulnerable to dental caries, theyare susceptible to mechanical complications and peri-implant,biofilm-induced inflammatory tissue changes. A 10-yearretrospective study48 of 397 fixed-implant reconstructions in 300patients observed a mechanical complication rate of 24.7%. Themost frequent complication was ceramic chipping (20.31%),followed by occlusal screw loosening (2.57%) and loss of retention(2.06%). Although relatively infrequent, occlusal screw looseningcan result in a subgingival gap at the implant–abutment junctionthat retains plaque and stimulates an inflammatory reaction in softand hard tissues.Biologically, biofilm accumulation due to inadequate or no accessfor oral hygiene can result in peri-implant mucositis and peri-implantitis. Peri-implant mucositis is characterized byinflammation confined to the soft tissue and is reported to affect upto 80% of patients with dental implants.25 Peri-implantitis ischaracterized by peri-implant inflammation with progressivecrestal bone loss beyond the initial remodeling. The prevalence ofperi-implantitis among patients is 11.2% to 53%.27,37,38-40 Poor oralhygiene, residual cement, current or history of periodontitis,cigarette smoking, and diabetes mellitus are risk factors for peri-implant diseases.1,9The relationship between peri-implant mucositis and peri-4593 implantitis is similar to that between gingivitis and periodontitis.Although peri-implant mucositis does not necessarily progress toperi-implantitis, it is likely the precursor to peri-implantitis.1 Theinflammatory response in peri-implant disease appears to besimilar to that in periodontal disease.41 However, the severity andrate of disease progression appear to be more pronounced aroundimplants. This may be caused by the absence of a self-limitingprocess, which is observed in periodontitis, around implants thatseparates the inflammatory cell infiltrate from the bone.6Experimental models demonstrated that peri-implant mucositiswas reversible at the biomarker level (i.e., matrix metalloproteinase8 [MMP-8] and interleukin-1β [IL-1β]).41A review of the literature36 reported that peri-implant mucositiscould be effectively treated with nonsurgical mechanical therapies,but these modalities tended to be ineffective against peri-implantitis. Results of surgical treatment for peri-implantitis are notpredictable. Prevention, early detection, and early treatment of peri-implant diseases are therefore crucial. Periodic and well-regimented supportive implant treatment is essential to the long-term success of dental implant therapy. Key FactImplants are susceptible to mechanical complications and biofilm-induced inflammatory diseases, such as peri-implant mucositis andperi-implantitis.Examination of ImplantsThe supportive implant treatment appointment should include: aninquiry about new concerns, problems, or pain; review of changesin the patient's medical and oral status; evaluation andreinforcement of oral hygiene; examination and evaluation of softand hard tissue health; evaluation of implants and the associatedimplant restorations' stability and integrity; and professionalsupportive treatment. Assessment should determine theappropriate recall interval and plan for the next visit.4594 Examination begins with visual inspection for biofilm andcalculus accumulation; signs of inflammation and swelling; peri-implant soft tissue quality, color, consistency, and contour; andaberrations in the implant prosthesis. Peri-implant soft tissue can bedigitally palpated to detect edema, tenderness, exudation, orsuppuration. Peri-implant probing can be done to assess thecondition and level of soft and hard tissues surrounding implants.When indicated, radiographic images can be obtained to help verifythe level of the peri-implant crestal bone. Determination of implantstability or mobility and percussion testing can help verify implantosseointegration (Fig. 86.1).FIG. 86.1 Peri-implantitis. (A and B) Minimal biofilm accumulation isseen. The peri-implant mucosa exhibits minimal erythema and edema.Notice the buccal placement of the implant in B. (C) Manipulation oftissue indicates a lack of buccal keratinized attached gingiva andexudation from the peri-implant sulcus (arrow). (D) The periapicalradiograph shows peri-implant bone loss to the apex of the implant. Clinical CorrelationImplant examination includes evaluation of biofilm control, visualand tactile assessment of peri-implant tissue for inflammatorychanges and changes in probing depths, and radiographic4595 examination of the mesial and distal bone level.Peri-implant ProbingProbing of implants can be done with light force (i.e., 0.25 N) usinga traditional steel probe without adverse effects to the peri-implantmucosa.15 Implant probing should be recorded at the time of finalrestoration as the baseline measurement and done at least annuallythereafter.25Clinicians should use caution when evaluating peri-implantprobing because these measures cannot be interpreted the same asprobing depths around teeth. Although periodontal probingaround natural teeth is useful for assessing the health ofperiodontal tissues, the sulcus or pocket depth, and the level ofattachment, probing around implants may not provide comparableresults.7 Due to distinct differences in the tissues that surround andsupport teeth compared with those that surround and supportimplants, the probe inserts and penetrates differently. Aroundteeth, the periodontal probe is resisted by the health of theperiodontal tissues and importantly by the insertion of supracrestalconnective tissue fibers into the cementum of the root surface.These fibers, which are unique to teeth, are the primary source ofresistance to the probe.3 There is no equivalent fiber attachmentaround implants. Connective tissue fibers around implants usuallyrun parallel to the implant or restorative surface and do not haveperpendicular or inserting fibers (see Chapter 74). The primarysource of resistance to the probe depends on the conditions aroundthe implant.12,24 At noninflamed sites, the most coronal aspect ofconnective tissue adhesion to the implant resists the probe. Atinflamed sites, the probe tip consistently penetrates farther into theconnective tissue until less inflamed connective tissue isencountered, which is often close to or at the level of bone.The value of peri-implant probing is different from periodontalprobing and offers comparatively limited information. Probingaround implants can measure the level of the mucosal marginrelative to a fixed position on the implant or restoration and canalso measure the depth of tissue around the implant. The peri-implant probing depth is often a measure of the thickness of the4596 surrounding connective tissues and correlates most consistentlywith the level of surrounding bone. However, peri-implant probingis affected by several conditions, including the size of the probe, theforce and direction of insertion, the health and resistance of peri-implant tissues, the level of bone support, and the features of theimplant, abutment, and prosthesis design (Fig. 86.2).FIG. 86.2 Buccal probing of the implant is impeded bythe implant restoration.A comparison45 of probing pocket depth of implants with peri-implantitis before and after the removal of the prostheticrestorations reported similar probing depths in only 37% of sites. In39% of sites, the difference was ±1 mm; in 15% of sites, it was ±2mm; and in 9% of sites, it was ±3 mm. Probing measurements canbe an accurate measure of soft tissue thickness around an implant(i.e., peri-implant soft tissue above the bone level), but in manycases or sites, the inability to properly angle and direct the probealong the implant can lead to inaccurate assessment of soft tissuethickness. In these situations, the clinician must appreciate thelimitations and know that other clinical parameters andradiographs are required to help evaluate the peri-implant'scondition.Probing around implants is likely to vary more than aroundteeth. Studies have shown that a change in probing force aroundimplants results in more dramatic changes than a similar change inprobing force around teeth.29 The probing depth around implantspresumed to be healthy (and without bleeding) has been4597 documented as about 3 mm around all surfaces.2,8 The absence ofbleeding on probing around teeth has been established as anindicator of health and a predictor of periodontal stability.21 Studiescomparing bleeding on probing around teeth and implants in thesame patient have reported that bleeding around implants occursmore frequently.Bleeding on probing at implant sites can indicate inflammation inthe peri-implant mucosa. However, the ability to use bleeding onprobing as an indicator for assessing diseased or healthy sitesaround implants has not been established. Due to the potential forfalse-positive bleeding (i.e., provoked bleeding) with probing, theuse of marginal bleeding, which is a more sensitive indicator ofinflammation and is less likely to elicit false-positive bleeding, hasbeen proposed to assess peri-implant inflammation.50 Marginalbleeding can be evaluated by running a probe circumferentiallyalong the coronal portion in the implant sulcus. Overall, the valueof peri-implant probing is in monitoring changes in the probingpocket depth over time rather than the initial value because someimplants are placed apically for aesthetics.1 Clinical CorrelationProbing of implants can be accomplished with a traditional steelprobe. It is valuable for detecting tactilely inflammatory changes inthe tissue, such as loss of tissue to resistance to probe penetration,sponginess of peri-implant mucosa, and bleeding on probing, andfor monitoring changes in probing depth over time.Microbial TestingStudies in animals and humans have demonstrated thedevelopment of peri-implant mucosal inflammation in response tothe accumulation of bacterial plaque.5,33,41,51 Microbiologic studiessuggest that greater probing depths (i.e., pockets) around implantsharbor higher levels of pathogenic microorganisms.30,35,43 Studieshave also documented similarities in the microbial composition ofplaque in healthy periodontal sites compared with healthy peri-implant sites.31 Evidence indicates that the microbiota of diseased4598 periodontal pockets harbor the same pathogenic microorganisms asthose observed in inflamed peri-implant sites (i.e., peri-implantitis).31,43 However, there is no evidence to prove thatperiodontal pathogens cause peri-implant disease, and thepathogenesis of inflammatory disease around implants has notbeen defined.10One report1 accepted the idea that peri-implant disease, likeperiodontal disease, occurs primarily as a result of anoverwhelming bacterial insult and subsequent host response.Human biopsies indicate that peri-implantitis and periodontitisexhibit similar histologic features, including an inflammatory cellinfiltrate in the connective tissue dominated by B lymphocytes andplasma cells and by up-regulation of inflammatory biomarkers. Noevidence indicates that laboratory tests for the identification ofsuspected periodontal pathogens are of use in the evaluation ofimplants.14 The usefulness of microbial testing may be limited to theevaluation of peri-implant sites that are showing signs of infectionand bone loss, allowing the clinician to prescribe appropriateantibiotics.Stability MeasuresThe assessment of implant stability or mobility is an importantmeasure for determining whether osseointegration is beingmaintained. Important as it is, however, this measure has extremelylow sensitivity but high specificity. An implant can exhibitsignificant bone loss and remain stable; the stability measure in thiscase has a low sensitivity for the detection of bone loss. Conversely,if implant mobility is detected, it is likely that the implant is notsurrounded by bone; mobility is highly specific for the detection ofimplant failure or lack of osseointegration. Mobility demandsdifferentiation of loss of implant osseointegration from a looseimplant restoration.There is great interest in evaluating the stability of bone-to-implant contact in a noninvasive manner. Two noninvasivetechniques for evaluating implant stability are impact resistance(e.g., Periotest) and resonance frequency analysis (RFA). Originallydesigned to evaluate tooth mobility quantitatively, the Periotest4599 (Gulden, Bensheim, Germany) is a noninvasive electronic devicethat provides an objective measurement of the reaction of theperiodontium to a defined impact load applied to the tooth crown.The Periotest value depends to some extent on tooth mobility butmainly on the dampening characteristics of the periodontium.Despite dependence on the periodontium, the Periotest has beenused to evaluate implant stability. However, unlike teeth, themovement of implants and surrounding bone is minuscule, andPeriotest values therefore fall within a much smaller rangecompared with those for teeth. Detection of horizontal mobilitymay be a significant advantage of the Periotest because it is muchmore sensitive to horizontal movement than similar detection byother means, such as manual assessment.14Another noninvasive method used to measure the stability ofimplants is RFA,28 which uses a transducer that is attached to theimplant or abutment. A steady-state signal is applied to the implantthrough the transducer, and the response is measured. The RFAvalue is a function of the stiffness of the implant in the surroundingtissues. The stiffness is influenced by the implant, the interfacebetween the implant and the bone and soft tissues, and thesurrounding bone itself. The height of the implant or abutmentabove the bone influences the RFA value. Unlike the Periotest, theRFA does not depend on movement in only one direction. Theabsolute RFA values vary from one implant design to another andfrom one site to another, but there is high consistency for any oneimplant or location.The value of RFA is most appreciated with repeated measures ofthe same implant over time because it is very sensitive to changes inthe bone–implant interface. Small changes in tissue support can bedetected using this method. An increase in RFA value indicatesincreased implant stability, whereas a decrease indicates loss ofstability. However, this is a relative measure, and it has not beendetermined whether RFA is capable of detecting impending failurebefore the implant fails.Much interest and research have focused on the use ofnoninvasive methods to evaluate implant stability. Mobilityremains the cardinal sign of implant failure, and detecting mobilityis therefore an important parameter.4600 Implant PercussionTapping an implant's healing abutment or restoration with aninstrument produces a sound that can help determine itsosseointegration. A solid resonating sound and the absence of painusually indicate osseointegration. A dull sound can indicate that theimplant is fibrous encapsulated; radiographic and other clinicalfindings are needed for diagnosis.Radiographic ExaminationPerpendicular intraoral periapical radiographs should be taken atimplant placement, at abutment connection, and at final restorationfor baseline documentation of bone levels and annually11 thereafterto monitor marginal or peri-implant bone changes. In the setting ofperi-implant inflammation, a periapical radiograph is indicated forperi-implant bone evaluation and disease diagnosis. Periapicalradiographs have excellent resolution and, when takenperpendicular to an implant, can provide valuable details of theimplant-abutment junction, mesial and distal crestal bone levelrelative to the implant platform, and bone-to-implant interfacealong the length of the implant (Fig. 86.3). Periapical radiographsare difficult to standardize and great variation is inherent in theacquisition process, but they are relatively simple, inexpensive, andreadily available in the dental office. It is diagnostically importantto obtain images that clearly show implant threads (i.e., not blurredby nonperpendicular angulation) and the restorative implant–abutment connection.4601 FIG. 86.3 (A) A periapical radiograph captures thewhole implant. (B) A second perpendicular periapicalradiograph is necessary to assess the crestal bonelevel. Platform switching is seen at the implant–abutment junction.The objective of the radiographic examination is to measure theheight of bone adjacent to the implant, evaluate the quality of bonealong the length of the implant, and detect peri-implantradiolucencies. Although the predictive value of assessing implantstability with radiographs is low, films do offer a reasonablemethod to measure changes in bone levels.46 The predictive value ofdetecting implant failure or loss of stability is good whenradiolucent lesions are discovered with periapical radiographs.Identification of unstable implants is reliable when radiographs areobtained as part of an annual examination and when examiningpatients on a routine long-term basis.19The radiographic examination remains one of the primary toolsfor detection of failed or failing implants in routine clinicalevaluations, although it is not as accurate as mobility tests. In onestudy designed to evaluate the accuracy and precision ofradiographic diagnosis of mobility, the probability of predictingimplant mobility in a population with a low prevalence of implantfailures was low.46 Other studies, however, have demonstrated amuch higher predictive value for radiographic diagnosis of implantmobility.18,19 Investigators concluded that the most importantfactors for making an accurate radiographic diagnosis are thequality of the radiograph and the experience of the clinician.19,46 Flash BackIntraoral periapical radiographs of implants must be taken with thex-ray beam perpendicular to the implant fixture to enable clearvisualization of implant threads and the mesial and distal crestalbone levels.Assessment of Peri-Implant Health4602 Evaluation of Biofilm ControlImpeccable biofilm control is crucial to peri-implant tissue health.Poor biofilm control is associated with peri-implant disease (oddsratio =14.3).25 It is advantageous to evaluate biofilm control beforetissue manipulation. The amount and location of biofilm andcalculus accumulation should be assessed visually. Poor control istypically associated with biofilm and calculus retention and witherythematous and edematous gingival tissue. When biofilm controlis inadequate, the patient should be asked to demonstrate his or heroral hygiene routine in front of a mirror so that the clinician canevaluate the patient's technique. If the patient fails to removebiofilm in any areas, the patient's attention should be directed to thelocation of the biofilm. An instrument can be used to remove thebiofilm, with the patient paying attention so that he or she can seeits color and consistency. At this time, oral hygiene instructionshould be demonstrated and reinforced.Evaluation of Peri-Implant Health andDiseasePeri-implant mucosal health is characterized by pink, firm, andwell-adapted gingival tissue. Peri-implant disease is associated withclinical erythema, edema, and loss of tissue tightness around theimplant. Peri-implant mucosa can be nonkeratinized andunattached (see Fig. 86.1C) or keratinized and attached (Fig. 86.4C).In the setting of keratinized, attached mucosa, a gingival seal orgingival cuff is established around the implant.4 The gingival cuffcan protect the underlying bone and reduce subgingival plaqueformation. Due to the mobile nature of oral mucosa, the protectivefunction of nonkeratinized, unattached peri-implant mucosa maynot be as effective. However, the presence of keratinized, attachedgingiva, which can facilitate oral hygiene, is not a requisite for peri-implant health if biofilm is well controlled.44,49 Nonetheless, sitesdeficient in keratinized, attached tissue typically exhibit vertical orhorizontal ridge deficiencies, shallow vestibular depths, and long orbulky restorations. All of these factors can impede oral hygieneaccess and contribute to biofilm accumulation and peri-implant4603 inflammation.FIG. 86.4 (A) Subcrestal placement of an implant withadequate buccal and lingual bone thickness. (B)Periapical radiograph at the time of implant placement.(C) Implant at the 5-month osseointegration checkexhibits adequate peri-implant keratinized attachedtissue. (D) It also shows crestal bone remodeling to thefirst thread. Arrows indicate the mesial crestal bonelevel. Key FactPeri-implant health is characterized by pink, firm, and well-adapted peri-implant mucosa. Peri-implant disease is associatedwith erythema, edema, and loss of tissue tightness around theimplant.In cases of inflammation, the peri-implant tissue must bepalpated for tenderness and suppuration, the implant must be4604 probed, and periapical radiographs must be obtained andcompared with baseline images to determine peri-implant boneloss. Suppuration often indicates peri-implantitis.25 Radiographiccrestal bone loss beyond the implant baseline level at the time offinal prosthesis delivery in conjunction with bleeding on probing ischaracteristic of peri-implantitis.22 Due to potential measurementerrors, a threshold of detectable bone loss of 1.0 to 1.5 mm isrecommended for the diagnosis of peri-implantitis.42 In the absenceof a baseline radiograph, a vertical distance of 2 mm from theexpected marginal bone level after the initial crestal boneremodeling is recommended as the threshold for diagnosing peri-implantitis.42The amount of initial marginal bone remodeling depends on thedesign of the implant–abutment junction. Platform-switchedimplants (Fig. 86.5C; see Fig. 86.3), in which the abutment isinternally offset relative to the implant fixture at the implant–abutment junction, may exhibit less crestal bone remodeling thannon–platform-switched implants (see Fig. 86.4), in which theabutment is flush or even with the implant fixture at the implant–abutment junction.FIG. 86.5 Restoration is designed with adequatehygiene access. (A) Lingual view. (B) Mesial view of4605 the buccal contour. (C) The periapical radiographshows a gradual transition from the implant fixture tothe restoration. Platform switching is seen at theimplant–abutment junction.Evaluation of Implant OsseointegrationImplant osseointegration must be determined before fabricationand delivery of the final implant prosthesis. Implantosseointegration can be definitively determined only histologically,which requires the implant and the surrounding bone to beremoved. A combination of radiographic and clinical parametersare used to assess implant osseointegration or to rule out lack ofosseointegration. They include absence of peri-implantinflammation and pain in response to palpation and percussion, asolid resonating sound in reaction to percussion, completeradiographic bone-to-implant contact along the implant surface(i.e., absence of radiolucencies along the bone–implant interface),and implant stability.Evaluation of Implant RestorationsImplant superstructures, frameworks, and restorations should befabricated to accommodate and facilitate oral hygiene (e.g.,embrasure spaces made to allow passage of a proxy brush) (see Fig.86.4). Occlusal schemes of implant restorations should provideadequate posterior support, maximize axial loading, and minimizeincline contacts, nonaxial loading, and interferences in excursivemovements.During delivery, radiographs perpendicular to the implantshould be obtained for baseline documentation and to verifycomplete seating of the restorations. After delivery, cement-retained implant restorations should be thoroughly evaluated forresidual excess cement, which must be removed. During follow-upvisits, implant restorations should be carefully examined for heavycontacts, fractures, loose screws, and in removable prostheses,worn-out retentive components (i.e., Hader clips and locatorattachment inserts). Occlusion should be adjusted accordingly to4606 prevent implant overload and fractures of implant parts. Looseabutment and set screws must be evaluated, possibly replaced, andproperly torqued down. Worn-out retentive components must bereplaced periodically to ensure proper retention, stability, andfunction of the removable prosthesis. Occlusal wear of teeth and fitof tissue-borne surfaces of an implant prosthesis should be assessedand corrected as indicated. In patients with oral parafunctions andheavy occlusal forces, occlusal guards are recommended to protectimplants and restorations.Implant MaintenanceMethods for Patient Oral HygieneThe importance of good oral hygiene should be stressed evenbefore implants are placed, and peri-implant oral hygiene forbiofilm control should begin as early as possible after the implant isexposed to the oral cavity. A cotton tip, cotton gauze, or softtoothbrush can be used to gently remove biofilm from healingabutments or provisional restorations during the earlypostoperative phase of healing. Before implant osseointegration, theuse of powered toothbrushes should be avoided.After implant osseointegration has been achieved and verified,brushing with dentifrice can help remove deposits and increasesmoothness of exposed implant and restoration surfaces.32 Otherdental hygiene aids, such as dental floss, rubber tips, andinterdental brushes, can be employed (Fig. 86.6). Oral hygieneshould emphasize removal of biofilm and deposits along thegingival margin. Evidence for the use of a powered oral irrigatoraround implants is limited. One study reported that subgingivalirrigation of 0.06% chlorhexidine gluconate with a Waterpik device(Water Pik, Inc., Fort Collins, CO) was more effective at reducingbiofilm and gingival inflammation and produced fewer stains thanrinsing with 0.12% chlorhexidine gluconate once daily.164607 FIG. 86.6 Methods for patient oral hygiene are shown.(A) Flossing. (B) Bass method of brushing with anextra-soft toothbrush. (C) Interproximal brushing. (D)Removal of biofilm with a rubber tip. Hygiene methodsremove biofilm along the gingival margin.Methods for Professional RecallMaintenanceProfessional maintenance consists of the removal of dental biofilmand calculus from implant components exposed to the oralenvironment.26 Like root surfaces, the transmucosal surfaces ofimplants should be smooth to minimize plaque accumulation andto facilitate oral hygiene practices.23 At sites with excellent biofilmcontrol and peri-implant health, the need for professionalinstrumentation is minimal, and instrumentation should be limitedto prevent iatrogenic damage to implant components that cancontribute to plaque and calculus accumulation. In the setting ofbiofilm, calculus, and tenacious deposits, care should be taken tominimize damage to transmucosal implant surfaces. However,priority should be placed on the complete removal of implantsurface deposits.All metal instruments, including metal curettes and scalers, andultrasonic scalers increase the surface roughness of polishedtitanium.26 The use of plastic, Teflon-coated, and carbon and gold-4608 coated curettes and nonmetal ultrasonic tips have been advocatedto protect the titanium implant surface and the titanium abutmentfrom contamination by other metals and to reduce the likelihood ofscratching the surface. Unfortunately, the large size and flexibilityof nonmetal curettes may not allow effective biofilm and calculusremoval,34 and Teflon- and gold-coated curettes cannot besharpened.Most implant prostheses are made with gold alloys or ceramicmaterials, which are usually identical to the materials used inrestorations for the natural dentition. The location of the connectionbetween the restorative material and the implant is typically belowthe mucosa and often near the crest of bone; most calculus removalis done above this level. The fear of contaminating the titaniumimplant is therefore unwarranted. Gold alloy or ceramic surfacescan be debrided with most scalers and curettes (e.g., plastic, gold-coated, stainless steel) without damaging the surface. Rubber cupsand polishing paste can be used to remove biofilm and to enhancethe smoothness of machined and polished surfaces.Magnetostrictive and piezoelectric ultrasonic instruments withmetal tips (e.g., Cavitron) should be used with caution because ofirregularities that can easily be created in the surface.Treatment of Peri-Implant DiseasesThe goals of treatment are elimination of all peri-implant infectiousand inflammatory processes, prevention of disease progression, andpreservation and restoration of function and aesthetics. Treatmentbegins with patient education about the causes, pathogenesis, andprevention of peri-implant diseases, along with oral hygieneinstruction. Although bacteria are the main etiologic factor,systemic (e.g., smoking, poorly controlled diabetes) and localfactors (e.g., residual excess cement, poorly designed restorationsthat inhibit hygiene access) should be identified and modified.Peri-Implant MucositisPeri-implant mucositis can be effectively treated with nonsurgicalmechanical therapy.36 Treatment requires complete removal of4609 supramucosal and submucosal biofilm, calculus, and deposits usingcurettes, ultrasonic scalers, and polishing cups with prophy paste.Antimicrobials (e.g., chlorhexidine irrigation, mouthrinse) can beused with mechanical debridement to enhance treatment outcome.36Peri-ImplantitisThe treatment of peri-implantitis includes nonsurgical and surgicalinterventions, which can be combined with the adjunctive use ofantimicrobials. Nonsurgical interventions consist of antimicrobialrinse and irrigation, local antibiotics, ultrasonic debridement,mechanical debridement with air-abrasive devices, and lasertherapy. Surgical treatment includes full-thickness flap elevation foraccess, followed by degranulation, surface debridement by laser ormechanical instruments, surface decontamination with laser orantimicrobials, and bone augmentation. The data from twosystematic reviews13,47 are insufficient to suggest which interventionfor peri-implantitis is most effective or to allow specificrecommendations for the use of locally or systematicallyadministered antibiotics.Implant surface decontamination or disinfection remainschallenging, especially for implants with roughened surfaces. Forsome treatment modalities, recurrence of peri-implantitis appearsto be high (up to 100%) after 1 or more years of treatment, andretreatment may be necessary. Surgical access appears to benecessary to arrest peri-implant bone loss. Surgical treatment canresult in gingival recession and compromised aesthetics. At siteswith high aesthetic demands, definitive treatment of peri-implantitis can include the removal of the implant, grafting of thesite, and placement of another implant. Key FactTreatment of peri-implant mucositis is effective, whereas treatmentof peri-implantitis is unpredictable. Prevention, early detection,and treatment of peri-implant inflammatory diseases are essentialfor successful outcomes.4610 Referral of Patients to thePeriodontistThe previously described guidelines allow many implants to bemaintained quite well by primary dental care providers (i.e.,general dentists). Referral to a periodontist should be considered ifperi-implantitis or peri-implant mucositis is diagnosed and cannotbe resolved with improved oral hygiene and professionalmaintenance care. Early referral is advantageous to stopprogression and limit the extent of bone loss. Case Scenario 86.1Patient:73-year-old womanChief Complaint:Patient reports pain and bleeding in the back upper left whenevershe brushes.Background Information:The patient has hypertension, hypothyroidism, depression, andanxiety. She has smoked half to three-quarters of a pack per day onand off since age 17. Medications include lisinopril, levothyroxine,and duloxetine. She had a 12 × 14 fixed dental prosthesis restored10 years ago. She reports no pain or discomfort associated withimplants.Current Findings:The #14 implant is a Straumann tissue-level implant that is 4.8 mmin diameter. The patient has mild to moderate erythema andedema. There is no buccal keratinized tissue, and there is 3 mm ofbuccal recession. Buccal mucosa is loose and poorly adapted. Peri-implant probing depths are 4 to –5 mm. The first implant thread onthe buccal aspect is detectable with the periodontal probe. There isheavy biofilm.4611 CASE-BASEDQUESTIONSOLUTION AND EXPLANATION1. The clinical andradiographicinformation isadequate fordiagnosis andtreatment.A. TrueB. FalseAnswer: BExplanation: Although a vertical bitewing is shown and the mesialand distal crestal bones on implant #14 are visible, an additionalperiapical radiograph is required to enable complete visualization ofthe implant before a diagnosis can be made.2. Based on theinformationprovided, what isthe likelydiagnosis?A. Peri-implantmucositisB. Peri-implantitisC. HealthAnswer: BExplanation: Radiographically, it does not appear there is mesial ordistal bone loss, but the presence of biofilm, inflammation,recession, and buccal bone loss as detected by probing support thediagnosis of peri-implantitis.3. Treatment mustbegin with whichof the following?A. Patienteducationand oralhygieneinstructionB. Implantdebridementwith implantscalersC. Soft tissueaugmentationD. BoneaugmentationAnswer: AExplanation: The cause of peri-implant mucositis and peri-implantitis is biofilm. 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