Implant Patients

Implants are an increasingly popular choice for dental patients seeking solutions for missing teeth. They produce predictable results and have survival rates over 90%. ^61,62 In addition to preserving tooth structure and bone of adjacent teeth, patients report increased quality of life with better ability to chew foods.⁶² Once the implant is completed, there is no removable portion to care for, which is an added benefit.

However, it is important to understand the unique anatomy of an implant and how that differs from natural teeth. In addition to size and shape of the implant itself (which can differ quite a bit from a 2 or 3 rooted molar to a single post implant), implants are osseointegrated, meaning there is not a periodontal ligament (PDL) which helps keep natural teeth stable and supported.⁶¹ With the different structures we see slightly different disease processes. In peri-implantitis, there is no PDL space and therefore, infection can extend into the bone quickly making implants more susceptible to inflammatory processes.⁶¹

Patients should be educated on the importance of homecare prior to implant placement to ensure good routines are in place once the implant is placed. Peri-implantitis is most commonly caused by bacterial plaque around implant sites, therefore, effective plaque removal reduces risk of disease.^61,63 The last Cochrane review completed on interventions for maintaining tissue health around implants was conducted in 2010. Based on the two studies included in the review, the conclusion was that there was no, or very low, evidence for the recommendation that power brushes performed better than manual around implants.⁶⁴ However, a study conducted in 2018 with an O-R power brush using a specifically designed brush head (Interspace brush head) for areas that require special focus, such as implants (which looks similar to an end tuft brush. See Figure 5a) was compared with a manual brush. This study demonstrated that the O-R brush with the Interspace head can be effective at reducing plaque and bleeding.⁶³

Similarly, little research has been conducted on the WaterPik^® Sonic-Fusion brush specifically for implants. However, a RCT comparing string floss to a water flosser demonstrated the water flosser to be statistically more effective in reducing bleeding sites. Thus, water flossing may be a good adjunct for implant maintenance.⁶⁵ For study participants who liked sonic brushes, the combination sonic/water flosser may be very appealing. Or, for O-R users, adding the use of a WaterPik^®  water flosser is another option. Research has shown that this option is beneficial as compared to only using an O-R power toothbrush.²⁵

In 2016, Clinical Practice Guidelines for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental Restorations were created based on best evidence available for making recommendations for this population.⁶⁶ For at home maintenance it is recommended that patients should “be educated about brushing twice daily, and the use of oral hygiene aids such as dental floss, water floss, air flossers, interdental cleaners, and electric toothbrushes.”⁶⁶ More research needs to be conducted regarding implant maintenance to help strengthen recommendations and establish best practices, since the recommendations are based on very weak evidence.