Implant Maintenance: Is There an Ideal Approach?
For most patients, choosing to replace teeth with dental implants, whether it is a single tooth, several teeth, or to anchor a denture, is a significant investment, both physically and financially. Home maintenance is paramount to achieving a long-lasting, optimally functional, and comfortable prosthetic solution. While a standard of care for implant maintenance based on available research specific to implants has yet to be established, there are effective means and strategies for patients to clean the areas under and around implants and various prosthetic replacements.
The number of patients with implants is increasing exponentially, as implant dentistry has grown to become a $1 billion industry. The days of removable prosthetics are quickly decreasing, and replacement of a single tooth with an implant is favored over a bridge to prevent trauma to the surrounding teeth. Implants are a significant investment for individuals looking to replace one tooth, several teeth, or anchor a denture. Dental implants have been in existence for more than 20 years, yet, to date, there is no standard of care for home maintenance. Typically, traditional methods of brushing and flossing are recommended, and, in some instances, mouth rinses, specialty floss, or single-tufted toothbrushes are suggested.
As with natural teeth, the goal of oral hygiene is to prevent infection. If the mucosal tissue is infected around the implant, the diagnosis is peri-implant mucositis, or simply mucositis. This is similar to gingivitis in that the clinical signs are the same: redness, edema, and bleeding, but no sign of bone resorption.1 If there is loss of supporting bone, this is referred to as peri-implantitis.2 Mucositis occurs in approximately 80% of subjects (50% of sites), and peri-implantitis occurs in between 28% and 56% (12% to 40% of sites).3
A number of questions can be asked in regard to the high incidence of infection:
• Is the patient adhering to the maintenance schedule and home-care regimen?
• Was there a comprehensive treatment plan that addressed risk and contraindications?
• Was the prosthetic replacement too difficult to clean or poorly designed?
• Was the patient provided the tools for success?
Poor patient selection and insufficient treatment planning are ethical problems, but providing patients with the tools to clean their implants and motivating them to adhere to the regimen is an everyday activity in a dental office.
Approaches to Implant Care
Many dental professionals treat implants as natural teeth and recommend traditional methods of oral hygiene. Some companies offer implant kits with a few specialty products or devices to help with the unique challenges. However, implant maintenance is largely based on expert opinion, research of natural teeth, or professional experience. What is missing is evidence of what actually works best.
Choosing a toothbrush for implant care is not as simple as recommending a power brush versus manual. This is where oral healthcare professionals must put some thought into their decision-making if the research is lacking. A flat-bristled manual toothbrush would be ineffective for a patient with a bar attachment, but it may be suitable for a single implant replacement where the prosthesis dimensions are similar to the tooth replaced. In some areas the prosthetic replacement contours make it extremely difficult for a patient to clean.
Oscillating-rotating electric toothbrushes (OR) and sonic toothbrushes (ST) have both been studied with implants. In two studies an OR brush was evaluated more than 12 months for safety, efficacy, and patient satisfaction. Both studies reported a reduction in bleeding (up to 50% at 12 months) and probing depth (0.3 mm).4,5 The studies reported there were no adverse events, but there was also no control group. It is unknown if a manual device or other devices would fare the same or better in this study. Also, the examiners were aware of the protocol. The significance is that there was good patient acceptance and clinical changes, but a 0.3-mm change in probing depth—which was statistically significant—is most likely not clinically relevant with implants. One study showed a sonic brush was better than a manual brush for plaque and bleeding reductions over time, but there was no difference in gingivitis scores after 6 months.6
A systematic review evaluated the literature for effective maintenance regimens to maintain or recover soft-tissue health around implants. A meta-analysis was not possible because of the different interventions used in the studies. The authors found there was no statistically significant difference between powered and sonic toothbrushes compared to manual.7
Flossing is another area where the evidence needs to be examined. Patients are largely reticent to flossing their natural teeth, therefore it is realistic to think they will be resistant to flossing around implants. The reasons patients give for not flossing are: they say it is difficult, they forget, they don’t think they can master the technique, and/or it is uncomfortable.8,9 Given the option, patients will choose other devices over string floss.10 It is puzzling why oral health professionals continue to recommend floss when systematic reviews show no benefits when adding floss to brushing or for the reduction of interproximal caries.11,12
Flossing around some implants requires commitment, dexterity, and a different technique to maneuver the floss under or around the implant, bar, or prosthesis (Figure 1 and Figure 2). Flossing around implants is a necessity and patients need to understand that even though it is not a natural tooth, biofilm will form and can still adversely affect the tissue.
A water flosser (Figure 3), also known as an oral irrigator or dental water jet, has been compared to string floss in relation to efficacy for reducing gingival bleeding, inflammation, and plaque. Three studies demonstrate that a water flosser is more effective than string floss.13-15 Specifically, it is up to 50%13 more effective in reducing gingivitis and up to 93%14 more effective in reducing gingival bleeding.
A water flosser has also been tested with many patient types, including those with orthodontics, gingivitis, mild to moderate periodontitis, crown and bridge restorations, and people living with diabetes. Since chlorhexidine (CHX) is often recommended during implant placement to keep the tissue healthy, a study was conducted to compare rinsing with 0.12% CHX to irrigating with 0.06% CHX.16 The irrigation group was 87% more effective in reducing bleeding and three times more effective in reducing gingivitis than the rinsing group. Recently, a study compared the use of string floss to water floss with implants. The water flosser reduced bleeding around implants by 81% compared to 33% for flossing, a 2.46-fold difference.17 It should be noted that both studies used the Waterpik® Water Flosser (Water Pik, Inc., www.waterpik.com)—one with a subgingival tip and one with a specialized tip—and found it to be safe with implants (Figure 4).16,17
Because the research is minimal pertaining to implant maintenance, oral health practitioners must make a clinical judgment when advising patients on implant hygiene. First, they should decide if a manual toothbrush or power toothbrush would be best for the specific patient. They should consider toothbrushes that have special tip adaptions such as a small brush head or interdental tip (Figure 5); and they should demonstrate for their patients how to clean around the prosthesis using angulation and different attachments.
As noted above, the best product for implants may be a water flosser (Figure 3). Not only does it clean the interdental space and proximal surface, it can clean subgingivally, which is helpful when the pocket depth may be 4 mm to 6 mm. Toothbrushes, floss, interdental brushes, and antimicrobial agents cannot access this area. Water flossers also have different tips that can be useful: a tapered bristle jet tip is good for specialized cleaning (Figure 6); a tip with three tufts of bristles (Figure 7) is recommended for implants as well as crown and bridge restorations; and a subgingival tip can deliver an antimicrobial agent deeper into the pockets or under the prosthesis (Figure 4 and Figure 8). Specifically, the subgingival tip can reach 90% of a 6-mm pocket,18 and a classic tip can reach between 44% to 71% of shallow (0 mm to 3 mm) to deep pockets (> 7 mm).19 It has also been shown to remove the pathogenic bacteria in 6-mm pockets.20
Recent studies have also shown that a water flosser can remove supragingival plaque.21,22 This is an added advantage because people tend to form brushing habits that leave plaque on the tooth. For instance, a systematic review found that, after brushing, people removed an average of 43% of the plaque with a range of 28% to 53%.23 One study showed a water flosser was 29% more effective than string floss for removing plaque at the interproximal surface and had the added benefit of removing more plaque in areas such as the gingival margin, facial, and lingual surfaces.21 In addition, an ex-vivo study showed 99.9% plaque removal from treated areas of the tooth following a 3-second treatment on medium-high pressure. The surfaces were viewed under a scanning electron microscope.22
It may be assumed that using a sonic toothbrush can clean areas beyond the tooth surface. There is no published in-vivo research that supports this assumption, and a recent clinical trial evaluated the benefit of adding a water flosser to a sonic toothbrush. The study demonstrated that a sonic toothbrush and a water flosser was 34% to 70% more effective in reducing bleeding on probing, 23% to 48% more effective for reducing gingivitis, and 18% to 52% more effective for reducing plaque.24 The range is due to the different sonic toothbrushes used in the study.
Standard of Care
To date, there is no standard of care based on available research specific to implants. However, it seems apparent that a water flosser might be an ideal product for cleaning the areas under and around implants and different prosthetic replacements. This is because a water flosser:
• can clean supragingival, subgingival, and interdental areas18-20
• can remove supra- and subgingival plaque (biofilm)21,22
• was more effective for improving oral health than string floss with implants17
• was more effective than CHX for improving oral health with implants16
• is safe to use with implants16,17
• accomplishes most oral hygiene goals (with fewer products needed, patients are more inclined to adhere to a hygiene regimen)
• is easy to use
Not all water flossers, oral irrigators, or dental water jets function in the same way. It is prudent for oral healthcare professionals to review the research for all products before recommending them to their patients with implants. The majority of published studies have used a Waterpik Water Flosser, which has different pulsation and pressure configurations than other devices. To date, it is the only water flosser, oral irrigator, or dental water jet that has been compared to floss or used with implants in published research.
About the Author
Deborah M. Lyle, RDH, BS, MS
Director of Professional & Clinical Affairs, Water Pik, Inc., Morris Plains, New Jersey
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