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26 Dental Tribune Middle East & Africa Edition | May - June 2014hygiene tribune < Page 21 Figs. 2a-f: Cross over flossing technique. Fig. 3a: Excess cement on implant surface. Fig. 4a: Subgingival inflamma- tion due excess cement. Fig. 5: Plastic Scalers. Fig. 6a: 8 mm pocketing UR2. Fig. 6b: After subgingival curret- tage of the pocket the patient was shown how to use a large inter- dental brush with chlorhexidine gel twice a day. Fig. 6c: Patient reviewed at 2 weeks. The inflamed tissue have reduced exposing the crown margin. Fig. 6d: U2 pocketing has re- duced 5 mm. Fig. 4b: Note the excess cement on the implant crown. Fig. 4c: A healthy gingival cuff around an implant. Fig. 3b: Severe bone loss due to excess cement forced in to the tissues. sues it is essential that a light force is used (0.25 Ncm) to avoid trauma to the tissues. There is a parallel attachment of the junc- tional epithelium around the implant surface, therefore there is less resistance when probing around the implant. This will re- sult in deeper peri-implant prob- ing depths compared to probing around natural teeth. Peri-im- plant probing depths of implants placed in sites excluding the aes- thetic zone range between 2-4 mm under healthy conditions. In the aesthetic zone where the implant is usually placed deeper, the probing depths are greater than the normal range. It is important to note that most implant systems show evidence of a small amount of marginal bone loss within the first year of function. Smoking has been shown to be a risk factor to af- fect the long-term prognosis of dental implants therefore it is es- sential to assess the health of the peri-implant tissues regularly in smokers. What to do if there is bone loss? If there is on-going bone loss it is important to ascertain the cause. The causes of bone loss are: hygiene is performed to main- tain healthy peri-implant tis- sues. The use of toothbrushes, either manual or electric, helps to reduce the amount of plaque biofilm. Floss, including super- floss and interdental brushes is essential for access interproxi- mally. It is very important that oral hygiene for the patient is not made too complicated there- by prolonging the time required by using too many oral hygiene aids. In the aesthetic zone, a cross over flossing technique can be used (Figs. 2a-f). A poor flossing technique or no flossing at all can lead to subgin- gival inflammation of the peri- implant tissues. It is essential that if a cement retained crown is placed that all the cement is removed as subgingival irri- tants such as excess cement can provoke an acute peri-implan- titis which can cause soreness, swelling, bleeding on probing and eventual bone loss (Figs. 3 & 4). In premolar and molar areas the use of floss or intedental brushes can be easier for the patient in the case of single unit implant, and in fixed bridgework. Calculus formation on dental implants is very similar to that found on teeth, the only differ- ence is that the abutment and the porcelain are very highly polished, therefore the calcu- lus is not as tenacious as on a natural tooth. When removing supragingival calculus from the implant crowns, it is very im- portant not to use stainless steel scalers as this will damage the titanium surfaces. Therefore it is recommended that one uses a material that is softer than tita- nium either gold plated or rein- forced plastic instruments (Fig. 5). It is very important that an ultrasonic is never used on an implant as this will heat up the implant and could kill the bone that helps integrate the implant. When pocketing has been noted then using the CIST protocol will help treat the majority of peri-implantitis cases. Below is an example of an UR2 with 8 mm pocketing, the site was treated non-surgically with local delivery antimicrobials and with the patient using chorhexidine gel with the largest interdental brush (Figs. 6a-c). At the 2 week review the pocketing associated with the UR2 has reduced to 5 mm with simple non-surgical therapy any further intervention will need to be reviewed by the implant dentist. • Occlusal overload; • Bacterial induced inflam- mation. Any occlusal overloading needs to be corrected by the implant dentist. Plaque induced inflammation is initially treated non-surgically but depends on the initial clini- cal presentation. This involves the removal of dental plaque with or without the use of locally delivered or systemic adjuncts. Lesions with probing depth of 5 mm or more and bone loss of greater than 2 mm would need surgical intervention as recom- mended by the International Team for Implantology (ITI) consensus report Figure1. A common cause of plaque in- duced peri-implantitis is excess cement which has been forced into the tissue when the crown is cemented. If the excess cement is not thoroughly removed by the implant dentist, this will in- duce inflammation of the tissue and possible bone loss. How to maintain dental im- plants? It is important that good oral Conclusion Good oral hygiene performed by the patient has a significant affect on the stability of the marginal bone around dental implants. Therefore regular hy- gienist appointments are neces- sary to ensure that your patients are maintaining a high standard of oral hygiene around their dental implants. ORGANIZED BY Joint Meeting with NOVEMBER 14-15, 2014 JUMEIRAH BEACH HOTEL DUBAI, UAE E: events@cappmea.com M: +971502793711 www.cappmea.com ED BY IZERS