Abstract Dental implants, once thought to be experimental treatment modalities primarily designed for edentulous patients, are now considered standard of care for single- as well as multiple-tooth replacements. Tremendous advances have been made in the 21 years since the American Dental Association first approved the titanium screw as a treatment option in full-mouth reconstruction cases. Dental practitioners are now obligated to discuss implants as a treatment option when discussing tooth replacement as part of the informed consent process. Dental hygienists need to be educated in all aspects of implant therapy, including indications for treatment, the surgical process, implant biology, instrumentation, and patient self-care instruction.
Implant dentistry requires an ongoing collaboration between all members of the dental team to work as cotherapists to assist patients in maintaining or improving the function they had with their natural teeth. The dental hygienist is ideally positioned to contribute to this process through assessing the need for tooth replacement, addressing patient questions and concerns regarding the treatment process, maintaining the implant-supported prostheses, and educating patients in self-care techniques.1
After Swedish medical researcher Per Brånemark discovered in the 1950s that the hollow titanium rod he was using in a blood circulation experiment had attached itself to his animal subject’s bone, the term osseointegration was coined to describe the phenomenon of the direct biological attachment of vital bone to a titanium implant surface without any intervening connective tissue.2 Research over the past 40 years has transformed implantology from an unpredictable art to a well-grounded clinical science.3
Types of Dental Implants The 3 types of dental implants—subperiosteal, transosteal, and endosteal—are defined by the way they integrate into the alveolar bone.
The subperiosteal implant rests on the surface of the alveolar bone, under the periosteum. A titanium metal framework is cast from an impression of the surgically exposed edentulous ridge. The framework also can be made without surgical exposure of the alveolar ridge through the use of a computed-tomography (CT) scan. After placement, the titanium framework does not integrate into the bone. Instead, it becomes fixed to the bone via a fibrous connective tissue attachment. The gingival tissue heals over the framework, and posts protrude through the tissue providing a means of attachment for the prosthesis. Subperiosteal implants may be indicated for edentulous patients with narrow, atrophic alveolar ridges.2
The transosteal, or staple, implant is a titanium system that is surgically placed through the inferior border of the mandible and completely penetrates through the alveolar crest. An extraoral incision through the chin, in the anterior portion of the mandible, is required for placement of a transosteal implant system. Posts protruding through the mandible support the prosthesis. Edentulous patients with atrophic, narrow mandibles may be considered for a transosteal implant system.1,2
Endosteal implant systems are the only implants that are placed into the alveolar bone of the mandible or maxilla and are used to support a prosthesis. Four types of endosteal implants are available2,4:
• Blade Form: An early endosteal implant fabricated in a “blade” shape and surgically placed into the bone through a thin grooved incision. One or more abutments may be attached to the blade to provide support for the prosthesis (Figure 1). • Cylinder Form: An endosteal root-form implant featuring parallel-sided, nonthreaded walls. Cylindrical implants are usually pushed or tapped into a prepared bone site and rely on a variety of manufactured coatings to support osseointegration. • Screw Form: A root-form implant manufactured with threads similar to a hardware screw. The sides may be parallel or tapered. The threaded surface provides for retention during initial bone fixation as well as an increased surface area for osseointegration (Figure 2). • Transitional Implants: Used to support a provisional prosthesis while root-form implants are osseointegrating. Transitional implants are thinner in diameter and designed to support a provisional immediately on placement (Figure 3).
Implant System Components Root-form dental implants are currently the most widely used method of implant therapy, and often have success rates of more than 90%.5 Dental hygienists should be able to identify the various components of the endosteal implant for both instrumentation and patient self-care education.
Implant Fixture The fixture, or body, is the portion of the implant that is screwed or tapped into the prepared bone. Although the implant fixture is most often made of titanium, the outer surface is often treated with a variety of materials and techniques ranging from hydroxyapatite coatings to sandblasted or acid-etched surfaces. Each implant manufacturer has its own unique patented finishing process designed to enhance osseointegration.
In addition to surface properties and finishes, implant fixtures vary greatly in diameter, length, thread design, and taper. Currently there are 2 basic design categories, 2-piece and 1-piece. The 2-piece type, with an implant fixture and a separate abutment, is surgically placed in the bone followed by primary closure of the gingival tissues. After 3 to 6 months, once the implant has integrated into the bone, a second surgery is performed to attach a healing or restorative abutment to the fixture.5
The 1-piece type, an implant body and soft-tissue healing abutment manufactured as a single unit, is surgically placed with the upper edge coronal to the crest of alveolar bone. The gingival tissues are approximated around the implant, leaving the healing abutment exposed. No second surgery is required, and the restorative process can begin after osseointegration is complete.5 The dentist placing the implants must decide whether a submerged or exposed healing technique is most appropriate on a case-by-case basis.
Abutment The abutment serves as the connection between the fixture and the prosthesis or superstructure and is often contained within the peri-implant crevice. Abutment design, ranging from straight and conical to angled or ball-shaped, depends on the type of superstructure (single or multiple crowns, fixed or removable dentures) that the implants have been placed to support. The abutment design also varies depending on whether the superstructure will be cement- or screw-retained or if it will be an attachment device for a removable denture. Screw design and selection depend on the implant manufacturer, the implant load, and the practitioner’s personal preference.2,4
Implant-supported Restorations Dental implants can support a variety of superstructures ranging from single crowns to full dentures. Retention methods will vary depending on the restoration.
Removable Prosthetic Appliances The edentulous patient experiences approximately a 25% decrease in bone width and an overall 4-mm decrease in bone height in the first year after tooth loss as a result of the lack of stimulation provided by natural teeth. This bone loss often is accelerated by an ill-fitting, soft-tissue–supported denture.4 An implant-supported prosthesis will stimulate and maintain bone dimensions similarly to natural teeth, as well as enhance esthetics, function, and speech.4 Furthermore, a single titanium dental implant can support forces up to 100 kg, far greater than the average maximum occlusal force (< 23 kg) that can be borne by an edentulous patient.4,6 A variety of options are available for implant-supported, removable prostheses, ranging from ball-and-socket abutment connections to the Hader bar-and-clip system. The Hader bar-and-clip system, developed in the 1960s by Hemet Hader, features 3 different retention strengths and a 20° clip rotation, providing increased flexibility for retaining the overdenture, whereas ball-and-socket designs rely on an O-ring for a more rigid attachment (Figures 4 and 5).4
Fixed Full Prostheses Edentulous patients also may be candidates for fixed full prostheses ranging from screw-retained overdentures to individually placed implant crowns. The choice depends on the needs and health of the patient, the quality and quantity of hard and soft tissue available, and the experience level of the practitioner (Figure 6).4
Single-unit Restorations Single-unit implants may be placed in full-mouth reconstruction cases to replace several teeth lost to trauma or disease or as a treatment option alternative to a fixed bridge or removable partial denture. This use of implants is the fastest growing area of implant dentistry. Single-unit implants that promote the conservation of the adjacent teeth are often the treatment of choice for both the patient and the practitioner over the more traditional fixed bridge tooth replacement option (Figures 7 and 8).7
Implant Retention Options Implant restorations or prostheses may be either screw- or cement-retained, depending on the location of the restoration and the preference of the restoring dentist. Screw-retained restorations have an access hole that is covered with a composite material. Cement-retained restorations are bonded to the abutment in much the same fashion as a crown. With either system, the restoration may become loose and need to be reconnected to the abutment.8 Distinguishing a cement-retained single-unit implant restoration from a natural tooth without an accompanying radiograph often is difficult (Figures 9 and 10).
Implant Biology The soft tissues surrounding the implant, which are similar to those of natural teeth, are called the peri-implant tissues, and their interface with the implant fixture and abutment is called the biologic or permucosal seal.2,4,9 The biologic seal forms following a series of events after implant surgery. The attached gingiva regenerates around the implant forming an epithelial cuff or collar. Epithelium then regenerates in this newly formed sulcus and forms a nonkeratinized epithelial lining as well as a zone of epithelial cells at the base of the sulcus, creating an interface with the implant surface. This seal, formed by the junctional epithelium, creates a physiologic barrier, protecting the implant–bone interface from the insults of bacterial plaque, biofilm, and the mechanical forces and oral hygiene maintenance procedures.2,4,10 The gingival sulcus depth of a dental implant averages between 1.3 mm and 3.8 mm, whereas the average sulcus depth around a healthy natural tooth averages between 0.4 mm and 3 mm.11 Optimal self and professional care is required to preserve the health and integrity of the biologic seal.4
The connective tissue located between the crest of the alveolar bone and the junctional epithelium in the peri-implant tissues differs from that of a natural tooth in several aspects because it lacks a periodontal ligament and cementum. The blood supply to the peri-implant tissues must come solely from the adjacent alveolar supraperiosteal blood vessels because of the missing periodontal ligament.12 The connective tissue bundles run parallel to the implant abutment and no connective tissue fibers are attached to the implant surface as in the cementum of a natural tooth. The connective tissue adjacent to an implant contains more collagen, fewer fibroblasts, and a reduced blood supply as compared with the gingival tissues surrounding a natural tooth.13 These biologic differences clarify why the peri-implant mucosa has a diminished capacity for self-repair in the presence of inflammation (Figure 11).12,13
Osseointegration Successful integration of the titanium fixture into the prepared implant site is influenced by a number of factors. First and foremost are the quality and quantity of the patient’s bone, followed by careful and aseptic surgical techniques. Advances in bone grafting techniques and CT imaging have increased the success rate for individuals previously considered to have inadequate or compromised bone.
Osseointegration also requires an adequate amount of uninterrupted healing time for bone cells to integrate to the implant fixture. The average time for osseointegration ranges between 3 and 6 months, depending on the density of the bone. Typically, implants placed in the mandible integrate more quickly than those placed in the maxilla.4,11
The Implant Treatment Process Successful implant therapy requires the expertise and commitment of all the involved dental specialists. Practitioners providing implant services must stay current with the many advances being made in implant dentistry. No official recognition exists today of specialty status for implant dentistry in the United States. Although oral surgeons and periodontists have become responsible for many of the surgical aspects of implant placement, general dentists and prosthodontists also may be trained to perform the surgical procedures. The American Board of Oral Implantology/Implant Dentistry (ABOI/ID) administers a rigorous certification and examination program for dentists wishing to become certified as Diplomates in Oral Implantology/Implant Dentistry. Although the ABOI/ID is not recognized as a specialty board by the American Dental Association (ADA), the ABOI/ID closely adheres to the ADA’s Requirements for National Certifying Boards for Dental Specialists in the administration of their program and examinations.14
The Dental Hygienist’s Role The dental hygienist has an important role to play throughout the implant therapy process. The dental hygienist often has an established relationship with patients and is directly involved in educating patients regarding options for replacing missing teeth. The hygienist also educates patients about the restorative process, especially ongoing continuing care needs.
Presurgical Phase The presurgical phase consists of the appointments involving the implant planning process. The initial discussion and evaluation may begin during a continuing care appointment or at a separate consultation appointment. In either case, the patient’s health history is evaluated and any medical conditions that could influence the success or failure of implant therapy are discussed. Current research indicates that predisposing factors, such as age, diabetes, smoking, and preexisting periodontitis, are no longer considered to be absolute contraindications for implant therapy.15-17 Although individuals with such preexisting conditions may exhibit delayed healing responses, these factors do not necessarily predispose them to implant failure.15-17 Of possible exception may be individuals with a history of intravenous bisphosphonate therapy for cancer treatment, who are at increased risk for osteonecrosis of the jaw. The contraindications are less defined in individuals with a history of oral bisphosphonate use for osteopenia and osteoporosis where the number of reported bone exposures has remained very small.18 Inadequate or poor-quality bone, occlusal overload, and peri-implantitis, as well as poor surgical technique, are of greater concern in predicting implant failure.
After evaluating the patient’s general health, his or her dental health is reviewed. Points to consider include:
• Patient’s chief complaint • Bone quality and quantity • Soft tissue quantity and quality • Number of missing teeth • Cause of tooth loss • Patient motivation for tooth replacement
Impressions for study casts would be made and radiographic studies should be ordered, including a panoramic x-ray, full-mouth series, and possibly a CT scan or tomograph, depending on the location and number of missing teeth.
The second presurgical appointment has 2 parts: (1) a consultation with the implant surgeon regarding the placement of the implant fixtures and any anticipated bone grafting and soft-tissue engineering; and (2) a consultation with the restorative dentist regarding the final restorations. A surgical stent to guide the surgeon in the placement of the implant fixtures may be fabricated during the presurgical phase as well as the provisional restoration for immediate temporization cases.
Surgical Phase The surgical phase consists of the actual placement of the implant fixtures. Today many implant surgeries may be performed in one stage depending on the specific case and the preference of the surgeon. The implant fixture is placed in the bone and a healing cap is placed over the fixture. In some cases, the implant fixture may be placed immediately following tooth extraction. Instead of covering the fixture with the soft tissue, the tissue is sutured around the implant and the healing cap remains exposed during osseointegration.
Not only does the 1-stage technique eliminate the need for a second surgical procedure, but it also can reduce the amount of time required for the entire treatment process. Not all cases are appropriate for a 1-stage surgical procedure; however, it is a valid option to consider in the overall treatment planning process.
The greatest patient concerns regarding implant surgery often center on the level of discomfort or pain associated with the process. Although only a local anesthetic is required for the actual placement, many patients may choose some form of conscious sedation. Postoperative discomfort has been compared with that of having a tooth extracted.
Restorative Phase The restorative treatment is completed by the general dentist or prosthodontist. After the implants have integrated, as determined radiographically, appointments may be scheduled to complete the prosthesis or individual crowns. The restorative appointment series consists of impressions, try-in appointments, and the final delivery. Complications during the restorative process may arise if the implant fixture has not been placed in the bone as originally planned because of inadequate bone or unforeseen complications during the surgical process. Prosthetic design and distribution of the occlusal forces play critical roles during the restorative phase and in determining the long-term success of the implant.11 After the restorative process is complete, hygienists should review the daily oral hygiene techniques, emphasizing strategies for cleaning the implant-supported restoration.
Complications Implant Failure Implant failures are classified as early, when osseointegration fails to occur (Figure 12), or late, when osseointegration fails after a period of function.5 Failures are further categorized as biological, caused by infection or other systemic factors, or mechanical, caused by occlusal overload or similar factors.5 A failed implant is mobile and may be symptomatic, in spite of osseointegration. Radiographically, a failed implant has fibrous tissue in place of an implant–bone interface.2,5 When tapped with a metal instrument, a failed implant will make a dull, flat sound indicating the presence of fibrous connective tissue at the implant–bone interface. An osseointegrated implant will make a ping tone when tapped with a metal instrument, indicating an implant–bone interface. Failed implants need to be removed by the surgeon, and the site evaluated for re-treatment.
Peri-implant Disease Peri-implant disease is a collective term for the inflammatory reactions in the soft and hard tissues surrounding dental implants.2 Peri-implant mucositis is a reversible, inflammatory reaction in the soft tissues surrounding an implant, while peri-implantitis is an inflammatory reaction of the soft and hard tissues with a subsequent loss of supporting bone surrounding an implant.2,19 Bacterial plaque biofilm will form on implant surfaces as soon as they are exposed in the oral cavity. The initial pellicle formation is similar to that on natural teeth. Periodontal pathogens identified in pockets before implant placement can be detected at implant sites within 3 months following implant exposure.20 Implants and their supporting tissues are often described as ailing or failing, depending on the extent of the inflammation.2 Research shows that peri-implant tissue is colonized by the same bacterial flora as the periodontium and that disease of these tissues follows a similar progression to gingivitis and periodontitis.21
Maintaining Implant-supported Restorations Maintenance of optimal peri-implant health and disease prevention should be the goals of any continuing care program. The first maintenance appointment should be at the time of the initial assessment, before the placement of the implants. The patient should understand the overall importance of conscientious self-care for optimal oral and systemic health, along with the importance of good oral hygiene as it relates to the success or failure of the implant.
After the implants have been placed, the implant-supported restoration and surrounding soft tissue should be evaluated for the following at each maintenance appointment11,22:
• Quality of the peri-implant tissue • Presence of plaque and calculus (Figure 13) • Radiographic appearance of the implant and peri-implant structures • Presence of suppuration at the abutments • Mobility of the abutment or restoration • Presence of salivary percolation resulting from pressure applied to the restoration • Patient comfort and function
Currently, no specific formal protocols are outlined in the professional literature for implant continuing care intervals.21 The hygienist, in consultation with the dentist, should make an appropriate continuing care schedule based on the complexity of the implant restoration, the overall periodontal condition, and the patient’s self-care abilities and motivation. Peri-implant infections can progress more rapidly than in a natural tooth, and mucositis has been shown to lead to implantitis following 3 months of plaque biofilm accumulation. With this in mind, some researchers recommend initiating a 3-month continuing care interval in the first year following implant placement.4,23 The interval can be later extended to 6 months in some cases, depending on the gingival health, oral hygiene status, and any additional risk factors.23
The Implant Assessment Process The first step in the continuing care appointment is the assessment of the peri-implant tissues for the presence of visible plaque biofilm and calculus and any accompanying inflammation. The tissue surrounding the implant should be carefully evaluated for erythemia, edema, changes in contour and consistency, as well as the presence of any suppuration or percolation around the sulcus.
Radiographs should be taken depending on the schedule determined in consultation with the treating dentist. Radiographic interpretation has been shown to be a valuable measurement of implant success or failure.24 A variety of imaging modalities from standardized periapical x-rays to high-resolution panoramic systems may be used, depending on the individual clinical circumstances and the anatomical needs of the patient.
The radiograph should show the formation of bone at the implant fixture interface. The anticipated crestal bone loss during the first year following placement is approximately 1 mm with an anticipated 0.1 mm of bone lost in each subsequent year following placement.25 It is important to document the technique used for the particular x-ray taken so that it can be replicated on subsequent examinations for an accurate comparison of the images.
Periodontal probing continues to be a controversial issue and the recommendations for probing intervals vary, depending on the investigator.26 In the absence of inflammation, the benefits of probing peri-implant tissue has been questioned, and some researchers have found that radiographs and visual assessment are more reliable indicators of implant health than probing depths.27 In some cases, especially in single-unit implants, the anatomy and the position of the restoration may restrict access to the peri-implant sulcus, making a parallel probe insertion impossible.
If the peri-implant sulcus is to be probed, it is important to establish a baseline for comparisons over time and to use a fixed reference point on the implant abutment for measuring the attachment levels. A plastic instrument must be used to avoid scratching the titanium implant surface. The biologic seal around implants is more sensitive to force variations than around natural teeth, and concerns have been raised about the possibility of introducing pathogens by penetrating this seal during probing.28 Bleeding on probing, usually indicative of active disease around a natural tooth, may be caused by traumatizing the biologic seal around the implant fixture. Probing is contraindicated in the first 3 months following abutment attachment to avoid disrupting the newly formed biologic seal.29
Implant mobility should be monitored. Movement of the restoration could indicate a failure in osseointegration or, more simply, a loosening of the cement- or screw-retained prosthesis. It is not uncommon for 1 of the screws in the retention system, either at the fixture–abutment level or at the abutment–prosthesis level, to become loose. Loosened screws need to be tightened by the restorative dentist. In a screw-retained restoration, the integrity of the material used to seal the access hole should be monitored regularly. Wear patterns in this material or on the restoration itself as well as the opposing teeth may indicate the need for occlusal adjustment.4
Patients are also excellent sources of diagnostic information regarding the overall health of the implant. Pain or discomfort around the implant site may be the first indication of implant failure. Discomfort around the implant site may precede any radiographic changes.30
Self-care Strategies Effective self-care strategies are crucial for the long-term health of dental implants. Heavy plaque scores have been correlated to increased incidences of peri-implant mucositis.31 The importance of thorough, daily oral hygiene practices must be reinforced throughout the implant treatment process and maintenance appointment. Oral hygiene devices for implant maintenance should be selected to promote patient compliance as well as the specific requirements of the implant restoration. A table of self-care implant maintenance products can be viewed and printed at www.contemporaryoralhygieneonline.com.
When recommending oral hygiene aids, the dental hygienist must evaluate the position of the implant prosthesis and abutment and their relationship to the soft tissue, as well as patient motivation and manual dexterity. Successful plaque control will be limited if the procedures require an inordinate amount of time, a high degree of manual dexterity, or a multitude of devices.32 Studies have demonstrated that when multiple oral hygiene devices are recommended, their use decreases over time until only one device, the toothbrush, remains in use.32
Patients are often unclear of the exact configuration of their implant, abutment, and restoration. Showing them their radiographs can be an effective tool in assisting patients to visualize exactly where the implant body is in relationship to the restoration and will underscore the importance of supplementing toothbrushing with an additional aid to access the implant abutment.
The clinician must be familiar with the many products available to customize the recommendations based on the patient’s specific needs. The components of the patient’s home-care devices must be designed to be safe for titanium implant surfaces and not cause trauma to the peri-implant mucosa. The variety of plaque control devices available includes power brushes, soft-bristled toothbrushes of varying sizes and diameters, end-tufted brushes, and tapered rotary brushes. Interproximal cleaning devices need to be recommended in addition to whatever toothbrushing method has been selected. Numerous adjunctive devices are available, ranging from floss that has been specifically designed for implants to the rubber tip and proxibrush. Some patients may benefit from the use of an oral irrigator.
To decide which device to recommend, hygienists need to consider the position of the particular implant and the type of prosthesis attached to it (Figures 14 and 15). Then, consider if the patient’s manual dexterity is adequate to use the device being recommended, and if the device allows the patient to access the implant abutment to debride it thoroughly. An antimicrobial solution, such as 0.12% chlorhexidene gluconate, may be a beneficial adjunct to mechanical plaque removal devices. The chemotherapeutic agent can be applied locally to the peri-implant area by dipping the toothbrush, rubber tip, floss, or other plaque control device into a small capful of the chlorhexidene gluconate at the beginning of the home-care routine.32 Chlorhexidene gluconate also is useful during the postsurgical healing phases when mechanical plaque removal may be contraindicated.
Professional Maintenance Thorough debridement of the bacterial biofilm and any hard deposits is as necessary for dental implants and their prostheses as it is for the natural dentition. Maintaining the smooth surface integrity of the transmucosal titanium abutment plays a crucial role in the long-term health of the implant. After the patient’s soft tissue has been assessed and plaque control strategies have been reviewed, the clinician should debride the abutment and prosthesis.
Calculus formation on implant surfaces may be softer and less tenacious than the calculus found on natural teeth. Supragingival calculus is more common on implants than subgingival deposits.1 All implant and restorative components, both within and above the peri-implant crevice, should be debrided of plaque and calculus to maintain the health of the peri-implant tissues.
Scanning electron microscopic studies have shown that metal instrumentation produces scratching of the titanium implant abutment interface causing greater plaque retention and inflammation of the peri-implant tissues.33 Therefore, instruments and other debridement devices made of materials that are not damaging to titanium surfaces should be used. A variety of plastic and graphite as well as gold-tipped hand instruments are available for instrumenting implant-supported restorations. Ultrasonic and sonic instruments are available with plastic, carbon, or ceramic sheaths designed to be safe for debriding implants. A table of professional products for implant maintenance can be viewed and printed at www.contemporaryoralhygiene.com
Because implant-supported restorations can range from single-unit restorations to overdenture attachments or fixed dentures, a variety of instruments and strategies may be required for effective debridement. In terms of instrumentation, it is helpful to consider individually the 3 different components that need to be debrided.
The implant-supported restoration, or prosthesis, can be a single crown, multiple crowns, an attachment bar, or a device for an overdenture. These restorations do not require specialized instruments designed for use with implants because they are merely restorations supported by an implant abutment. Any instrument that is compatible with the restorative material can be used. Metal instruments are safe to use as long as they do not contact the abutment surface.34
Debriding the implant abutment area requires the use of specialized implant instruments. Although plaque and calculus can form around implant abutments as easily as on natural teeth, debridement must be performed with caution to preserve the integrity of the easily scratched titanium abutment surfaces. A variety of plastic, Teflon-coated, and gold-tipped instruments have been designed for removing plaque and calculus from dental implants (Figure 16). Plastic probes also are available for use around implants. Instrument selection should be made on the basis of the abutment angle, its location, and the nature of the deposits on its surface. The debridement instrument selected for the implant-supported restoration in Figure 8 will be quite different from the instrument selected to debride the implant-supported prosthesis in Figure 6.
Single-tooth implant replacement crowns pose special challenges in accessing the supporting implant abutment. The circumference of the crown or base is often much wider than the abutment, making it difficult, if not impossible, to access the peri-implant crevice with an instrument. In these cases, it is only necessary to deplaque the crevice with an alternative plaque removal aid, such as floss (Figure 17).34
Implant fixture debridement may be necessary in the case of peri-implant disease. In a healthy implant, the threads or roughened surface of the implant fixture will be below the biologic seal and not visible. In the case of bone loss, the implant threads are exposed. The exposed areas may be deplaqued with a brush. If calculus is present, an appropriate hand or power instrument may be used.
Power instrumentation may be used when large amounts of calculus and plaque need to be removed from the restoration and the abutment. Care should be taken that only power instruments that have specially designed implant tips are used at low power and with ample irrigation (Figure 18).34
Polishing dental implants and implant restorations should be performed with the goal of removing soft debris while maintaining the surface integrity of the titanium. In general, implant-supported restorations should only be polished when necessary for stain removal and to restore their luster. The polishing agent should be selected based on the restorative material used. Low-abrasive pastes, cleaning agents, and dentifrices can be used safely on implant restorations.11
Conclusion Dental implants have become a routine and predictable treatment option for the replacement of missing teeth, enhancing an individual’s self-esteem and ability to eat and chew normally. Dental hygienists have an important role to play in implant therapy from the initial evaluation stages to long-term maintenance. An understanding of the restorative implant design, components, and soft-tissue anatomy will guide the clinician in instrument selection as well as debridement techniques.
Acknowledgement All clinical photographs courtesy of Patrick McEvoy, DDS, FAGD, Diplomate ABOI/ID.
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Catherine Draper, RDH, MS Cathy has been a dental hygienist for more than 30 years. She is past president of the California Dental Hygienists’ Association. Cathy is a 2005 recipient of the Sunstar Butler RDH Award of Distinction. She currently works in a general, cosmetic, and implant dental practice in Mountain View, California, and is a member of the adjunct faculty at Foothill College in Los Altos Hills. She presents continuing education programs on dental implants and the use of technology in dental hygiene practice. In addition to being an active member of CDHA and ADHA, Cathy has been a library reference associate, assisting patients and their families in accessing health information, at the Stanford Health Library for over 10 years. Cathy may be contacted at cdraper@cdha.org
Abstract
Types of Dental Implants 
Complications
• Quality of the peri-implant tissue 
Debriding the implant abutment area requires the use of specialized implant instruments. Although plaque and calculus can form around implant abutments as easily as on natural teeth, debridement must be performed with caution to preserve the integrity of the easily scratched titanium abutment surfaces. A variety of plastic, Teflon-coated, and gold-tipped instruments have been designed for removing plaque and calculus from dental implants (Figure 16). Plastic probes also are available for use around implants. Instrument selection should be made on the basis of the abutment angle, its location, and the nature of the deposits on its surface. The debridement instrument selected for the implant-supported restoration in Figure 8 will be quite different from the instrument selected to debride the implant-supported prosthesis in Figure 6. 
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