Good oral hygiene must take place before, during, and after placement of dental implants to ensure the health of the implant. Patients are concerned about what kind of maintenance their implants will require. Do they brush and floss their implants like regular teeth? Does food get underneath the fixed implant bridge or prosthesis? Patients look to their hygienists to address these concerns and help them with an individualized home-care routine.
The tissue surrounding the implant should appear pink, firm, and keratinized with no signs of infection. The peri-implant soft tissues (permucosal seal) that separates the connective tissues surrounding the implant from the outside environment should be keratinized tissue (see Figure 1). The absence of keratinized tissue has been documented to be more susceptible to pathogenic bacteria thus leaving the implant vulnerable to peri-implant disease.1 The success of the implant depends directly on the health of this seal, and the hygienist’s goal is to educate the client on how to obtain keratinized tissue and maintain a healthy permucosal seal.
Figure 1: Keratinized tissue surrounding the implant. Courtesy of Dr. Robert Horowitz
This reinforces the point that home-care must begin immediately and, if possible, before the implant is placed to maintain a healthy field and for optimal healing.
Once the implant is exposed to the environment, loaded (occlusal forces) and restored (see Figures 2a, 3b) a salivary pellicle is formed followed by bacteria with the formation of biofilm.2,3 The elimination of 85% of plaque/biofilm on a daily basis is critical to the overall health of the implant.4
Hygienists can prepare clients by providing home-care recommendations based on the individual treatment case. This begins with post-surgical home-care guidelines to ensure the clients feels comfortable and confident until they return for routine implant maintenance.3 (see Table 1). Always verify recommended guidelines with the implant surgeon’s recommendations.
Figures 2a, b: Placement of an implant. Courtesy of Keystone Dental
Knowledge of the implant titanium surface is necessary to fully understand what oral hygiene recommendations and products to present to clients. After 1990, a definite switch from smooth titanium alloy surface to a rougher implant surface transpired, which has proven to accelerate osseointegration. The addition of surface coatings to create roughness with plasma spraying, grit blasting, and etching has also proven to raise the bone-to-implant contact and accelerate osseointegration.5-7
To help the cliemt protect their implant(s), their investment, clients need to be aware of the following key points on choosing safe home-care products. First the product (for example, toothpaste or gel) needs to be low-abrasive to not scratch the surface of any exposed surfaces of the implant (exposed threads, for example). Avoid dentifrice with stannous fluoride, sodium fluoride (APF >3.0), baking soda, stain removers, and smoker’s toothpaste.
Figures 3a, b, c: Interproximal brushes. Courtesy of Hager Worldwide
What toothbrushes and interdental products are best to use with implants?
Several studies have been conducted regarding what type of toothbrush is most effective for implants. The results show no significant difference between sonic, electric, or manual tooth brushes. The main focus needs to be on adaptation to the prosthesis and the customer’s dexterity. Instruct the client to brush the implant(s) twice daily to remove bacterial plaque with a low-abrasive dentifrice. A soft toothbrush should be used; options include a manual brush, electric, or sonic brush (examples include Oral-B Triumph, Sonicare, and Waterpik Sensonic Plus), Sulcabrush, or end-tuft brush.
Figures 4a, b: Examples of implant floss. Courtesy of Hager Worldwide and Sunstar
Americas
Nylon coated interdental brushes/ proxabrushes are also an excellent alternative to clean especially tight and hard-to-reach areas around implants and prosthesis. Nylon only interdental brushes (no metal wire) are necessary to prevent scratching the implant or prosthesis. The interproximal brushes such as I-Prox P or I-Prox Plus work extremely well and can be dipped in non-alcohol antimicrobial rinse or gel. It is extremely important to brush under, around, and in the peri-implant crevice circumferentially (see Figures 3a-c).
Floss
There are many types of floss in the market, and generally it is highly recommended to use unwaxed tape or implant-specific floss in order to protect the tissue surrounding the implant. Alternatively for a bar-retained prostheses, full fixed retained prostheses, or wider interproximal spaces, a floss threader or a specialized floss that has a built-in threader is necessary (see Figures 4a, b).
Figure 5a: Insert floss on mesial and distal. Courtesy of Dr. Peter Fritz
To floss the implant, use dental tape and insert the floss in contacts on both sides of the implant. Wrap in a circle and crisscross in front, switch hands, and move in a shoe-shine motion into the peri-implant crevice, which is highly susceptible to inflammation/peri-implant disease due to biofilm1 (see Figures 5a, b).
In addition, antimicrobial mouth rinses may be recommended, especially if inflammation is present or if the client has dexterity problems, and difficult-to-reach areas. If the client is prone to inflammation, the use of an antimicrobial rinse, in conjunction with a rubber tip stimulator, may be recommended to inactivate bacteria substantive.12
Figure 5b: Crisscross floss and move in shoe-shine manner. Courtesy of Dr. Peter Fritz
Oral irrigators/Water Flossers
It is highly recommended for clients to use oral irrigators for the reduction of plaque/biofilm, inflammation, and hard-to-reach emergence profiles around implants 13,14 (see Figure 6a). Instruct the client to use a non-metal tip one to two times daily, and, if inflammation is present, add a diluted non-alcohol anti-microbial rinse (chlorine dioxide or chlorhexidine gluconate).
Studies using oral irrigators with implants for oral hygiene reveal that Waterpik Water Flosser is the only oral irrigator to date to be proven safe and effective with dental implants.15,16 A study was conducted to compare rinsing with 0.12% CHX to using a Waterpik oral irrigator with 0.06% CHX. The irrigation group using the soft rubber tip (PikPocket Tip, see Figure 6b) at lower pressure was 87% more effective in reducing bleeding and three times more effective in reducing gingivitis than the rinsing group.15
Another study of oral irrigation and floss revealed that the Waterpik Water Flosser with the standard tip with three bristle filaments (Plaque Seeker Tip, see opening page) used at medium pressure around implants was 81% more effective in bleeding reduction compared to 33% using floss.16 These specialized tips are very effective for implants and to deliver anti-microbial rinse around difficult-to-reach prostheses (All-on-4, full-fixed prosthesis, for example) in a prevention of peri-implant disease.
Figures 6a, b, c: From left to right, Waterpik Ultra Water Flosser, Waterpik PikPocket Tip, and Waterpik Traveler
Water Flosser
Water irrigation in conjunction with diluted non-antimicrobial rinse has proven to be extremely helpful for full-fixed and removable prostheses to remove daily biofilm and prevent inflammation if used on a daily basis. Waterpik makes a compact Traveler Water Flosser unit, which is my personal favorite to recommend ensuring clients to continue their home-care routine at home and away (see Figure 6c).
Stimulators
Stimulators are coming back into vogue with implants and regenerative procedures. Remember healthy keratinized tissue is the key to a healthy permucosal seal surrounding the implant. Stimulators are the ticket to achieve this, particularly in full-fixed, supra-structure implants, as well as implants that retain over-dentures (bar-retained implants). Examples of stimulators are rubber tip stimulators producted by multiple manufacturers and Soft Picks by Sunstar Americas (see Figures 7a, b).
Figures 7a, b: Examples of stimulators. Courtesy of Dr. John Remien & Sunstar
Americas
Instruct the client to place the tip of the rubber-tip stimulator so it lays flat against the gum tissue, not poking in the tissue, with pressure roll to massage and stimulate the tissue. The tissue will blanch or change to a lighter color when the correct pressure is applied.
A generalized home-care routine for implants is listed in Table 2 to be modified to individualize the clients home-care routine.
Note that a specific denture cleaner may be recommended for the overdenture. Plaque and bacteria can also accumulate on the inside of the overdenture, causing wear to the attachments and oral–systemic health complications for the client. Educate the client on how to do a visual check for attachments (O-rings, locator caps, and clips) and the importance of these attachments for retention. If attachments are worn or missing they will need to be replaced. O-rings and locator caps should be replaced once a year and clips as needed.17
Hygiene tip: Note the color and attachment type (O-ring, locator or clip) and record in the patient’s chart (see figure 8).
Figure 8: Note the color and attachment. Courtesy of Salvin Dental Specialties
Post-surgical implant placement home-care guidelines
- Drink only clear liquids; a soft diet is recommended for the first few days.
- Take all prescribed antibiotics to prevent infection.
- Take prescribed pain medication as needed for pain.
- Use an extra-soft toothbrush twice daily to clean pre-existing teeth or other implants, being careful to avoid the surgical incision area. If client uses an ultrasonic or electric toothbrush, wait one to two weeks.
- Clean between teeth once a day throughout the entire mouth except at the surgical site.
- Avoid wearing the temporary prosthesis provided or denture to let the gum tissue heal (if the implant was not immediately loaded).
- If recommended, use saltwater rinses or non-alcohol antimicrobial mouth rinse two times daily.
Implant Home-Care Guidelines
- Brush twice daily with low-abrasive dentifrice.
- Floss with dental tape (mesial/distal and facial/lingual) in shoe shine motion or use a water flosser one to two times daily.
- If recommended, use interdental brush, rubber tip, soft picks, and/or water irrigation unit one to two times daily.
- If inflammation present use non- alcohol anti-microbial rinse and/or add to water irrigation unit in 1:10 dilution.
Removable Prosthesis Guidelines
- Remove the prosthesis (overdenture) daily to soak in specific cleaner for recommended time only.
- Do a visual check of O-rings, locator caps, and clips. Alert dental professional if worn or missing, to be replaced.
- Remove the prosthesis from the cleaner and brush the underside with denture brush, being careful not to damage the attachments.
- Rinse off the prosthesis thoroughly with water and/or non-alcohol antimicrobial rinse.
- Rinse mouth with antimicrobial for 30 to 60 seconds and re-insert the overdenture into place.
Guidelines for care of your mouth after dental implant treatment:
- Take care to only have cold drinks and do not eat until the local anaesthetic has worn off. Avoid hot drinks or hot food for the first day and do not vigorously ‘swill’ liquid over the area. Try not to disturb the area with your tongue or fingers. Avoid undertake strenuous exercise for the first 48 hours (running / gym).
- Some swelling is normal and is usually worse in the mornings after lying flat all night. This will start to reduce after 48 hours. There may be some bruising on the skin which will also clear after a few days. Swelling can be reduced with ice packs (or a bag of frozen peas) wrapped in a towel. Hold on the cheek area for a maximum of 10 minutes at a time with 20 minutes break before applying again. After 24 hours gentle heat is more beneficial. Sleeping on 2-3 pillows may also help.
- Pain should not be a problem. Although you will be sore for a few days this can usually be easily managed with simple analgesics (pain killers) which you should take regularly for 2 days at the normal maximum stated dose. Take your first dose before the local anaesthetic has worn off. If pain seems to get worse after the first couple of days, rather than getting better, you should contact The Implant Centre.
- If you have a denture that covers the surgical area please wear it as little as possible for the first day to protect the underlying implants or graft. If the denture doesn’t seem to fit properly after your surgery then you must come back to have it adjusted. A badly-fitting denture can damage a healing implant.
- Any stitches will be dissolvable but often remain for around 2-3 weeks. If they are uncomfortable or annoying you may contact us to remove them after at least 1 week.
- Some bleeding following surgery is completely normal. If this persists apply pressure with a dampened gauze or clean handkerchief for 30 minutes.
- If you have been given antibiotics to take after your surgery then please complete the course.
- If you experience increasing pain or swelling after 2-3 days you should contact us for a review.
Cleaning – Successful implant surgery depends on keeping the mouth as clean as possible
- Please start to use the chlorhexidine mouthwash that you will be given, on the evening of surgery and continue for 1 week. You should hold half a cap-full over the surgical site for 1 minute, twice a day for 7 days. This will keep the healing site clean even if you are not able to clean it with a toothbrush.
- You should also start cleaning your other teeth with your toothbrush as normal on the evening of surgery. Avoid brushing the surgical site for the first few days, but then start to carefully clean this area as well when tenderness permits.
- Try to keep food away from the surgical area for as long as possible. Rinse following eating to keep the area as clean as possible.
- You are advised not to smoke until the wound has healed as this severely limits healing in the mouth.
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