Dental implant surfaces are primarily rough and porous. When this surface is under / attached to bone, it is not a problem; however, if this surface becomes exposed to the oral environment, either due to peri-implant bone loss or some other reason, it presents a BIG problem, as rough surfaces are very difficult to clean and disinfect. The biggest battle in treating peri-implantitis is being able to keep implant surfaces clean.

Once an implant surface becomes exposed, professional maintenance should increase in frequency to ensure consistent professional disinfection and also to detect any changes that occur around the implant. Early intervention is required to prolong the life of these implants.

Roughened implant surfaces can easily become contaminated with bacterial plaque, calculus, cement, frayed floss, and trace elements of plastic, graphite, carbon, or stainless steel (from dental instruments). Contaminants trigger inflammation that affects the tissues locally around the implant and systemically of the patient.

Powder air flow polishing systems are excellent at removing biofilm from implant surfaces. All instruments used to clean dental implants should be compatible with the type and material of the implants, abutments, and restorations. Titanium implant scalers are recommended to clean titanium implant surfaces, as like metals do not leave behind residues.

A typical implant maintenance appointment would go as follows:

• Place retractor to retract the cheeks and lips.
• Use of a subgingival air polisher with glycine powder (25 microns) with the subgingival-specific tip to remove subgingival biofilm. The tip is placed subgingivally until resistance is felt, then moved back slightly. Activate the tip for five seconds per site (six sites per tooth).
• Assess the peri implant tissues clinically (visual, probing: redness / swelling / bleeding / keratinized tissue amount, and quality). The tissue should be milked to determine if there is any exudate.
• Remove calculus and/or cement with appropriate instruments (short horizontal strokes, one thread at a time).
• Lavage before and after implant debridement using an ultrasonic or piezoelectric titanium compatible tip with short horizontal controlled light flow.
• Assess mobility (using two mirror handles) and occlusion.
• Take X-rays.
• Review oral hygiene instructions with patient.
• Book next maintenance appointment.

The goal of the implant maintenance appointment is to leave a clean implant surface, free of cement, calculus, biofilm, and residue, and to ensure the disease around the implant is controlled. 

Implant X-ray protocol

Take an X-ray:

• At each stage of treatment: Care must be taken to ensure the images show implant threads that are separate (not overlapped) and have clearly defined, sharp edges (not hazy)
• At any sign of infection or mobility
• At least once per year
• ALWAYS compare newest radiograph to baseline radiograph

For 1 to 4 implants: Vertical bitewings or periapicals of each implant

For 5+ implants: A PAN, CBCT, or individual PAs of each implant

Dr. Stacey Matheson is a board-certified periodontist in Halifax and has enjoyed serving Atlantic Canada for more than 20 years.