As you approach the holiday weekend, you're thinking of cookouts on the beach and Limoncello Martinis in your not-so-distant future, but you still have a few patients left to see before making a mad dash to the Hamptons (or in lieu of the Hamptons, perhaps, your local swim club). You've raced to the office, checked your hygiene schedule and there it is. You're confronted by a recall patient, a smoker with diabetes and perio and a variety of triggers, both genetic and external, that are upregulating their cytokines and inflammatory mediators, who has had an implant placed in the posterior maxilla and you've been noticing inflammation, pocketing and exudate. How do you treat this particular patient and specifically the implant which is starting to present with signs of peri-implantitis? Which products, instruments and protocols will be best for the natural teeth as well as the implant?
I posed this question to another one of Dental Girl's resident experts, Dr Gregori M. Kurtzman, and he provided us with his updated Protocol for Implant Maintenance, which differs slightly from our last protocol, presented by Dr Robert Delie.
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"The key to long term success with implants is how they are maintained and cared for both by the patient and during routine hygiene appointments. We will address some do's and don'ts to make implant care a success, " Dr Kurtzman told me and suggested that I post his protocol so that everyone can benefit from his years of expertise. I think that Dr Kurtzman's protocol will definitely provide food for thought over the holiday weekend, as we continue to search for support and protocols to help navigate the treacherous world of maintaining our implant patients and keeping them in the practice. Here is Dr Kurtzman's protocol and words of wisdom:
IMPLANT MAINTENANCE PROTOCOL
Gregori M.
Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA
·
Recall
o
1 week post restoration (check
occlusion)
o
1 month post restoration (check
occlusion)
o
3 month post restoration (check
occlusion and soft tissue as well as pt home care)
o
6 month recall schedule (unless perio
dictates more frequent)
·
Radiographic Exam
o
Evaluate Crestal Bone Loss
§ PA radiograph annually (standardized radiographic positioner with bite to
get exact position each recall)
·
Clinical Exam
o
Marginal Tissue Evaluation
§ Color (pink, red, cyanotic)
§ Consistancy (firm, boggy, swollen)
§ Comparison to adjacent areas
§ Keratinization
§ Recession (stability of the gingival margin)
o
Inflammation
§ Bleeding Evaluation
·
Probing (do not probe due to fiber orientation)
·
Digital palpation of gingival tissue
to evaluate presence of bleeding or exudate
o
Mobilty
§ Prosthetics
§ Implant fixture
·
Hygiene
o
Absence of inflammation with stable bone
level (without fixture collar exposure)
·
Prophy
·
Hand scalers/curettes (plastic,
graphite or titanium)
·
Ultrasonic with plastic tip
(optional)
·
Do not probe around fixtures due to
fiber orientation compared to natural teeth
·
Polish with prophy paste
·
Check occlusion
·
Recall 6 months
o
Presence of inflammation with stable
bone level (without fixture collar exposure)
·
Prophy
·
Hand scalers/curettes (plastic,
graphite or titanium)
·
Ultrasonic with plastic tip
·
Do not probe around fixtures due to
fiber orientation compared to natural teeth
·
Polish with prophy paste (avoid air
polishers)
·
Check occlusion
·
Recall 3 months
o
Presence of inflammation with fixture
collar exposure
·
Prophy
·
Hand scalers/curettes (plastic,
graphite or titanium)
·
Ultrasonic with plastic tip
·
Do not probe around fixtures due to
fiber orientation compared to natural teeth
·
Polish with prophy paste (avoid air
polishers)
·
Check occlusion
·
Recall 3 months (if inflammation
present still at next recall may wish to flap to clean or refer to periodontist
to have treated more aggressively)
·
Supplement home care with:
o
CHX rinse
o
Brush on FL2
o
Doxycycline 20mg 2x daily till next
recall (Periostat or generic equivalent)
o
Bone Loss with absence of
inflammation
·
Prophy
·
Hand scalers/curettes (plastic,
graphite or titanium)
·
Ultrasonic with plastic tip
·
Do not probe around fixtures due to
fiber orientation compared to natural teeth
·
Polish with prophy paste (avoid air
polishers)
·
Check occlusion
·
PA radiograph to monitor bone level
·
Recall 3 months (follow-up radiograph
to check stability of bone level)
·
Bone Loss with presence of
inflammation (no mobility to fixture)
More aggressive approach needed to stop the bone loss
progression, monitoring tends to allow progression and potential loss of the
fixture.
·
PA radiograph with reproducible bite
on holder
·
Flap procedure to eliminate any
debris (calculus, cement etc) subgingivally)
·
Hand scalers/curettes (plastic,
graphite or titanium)
·
Ultrasonic with plastic tip
·
Treat exposed threads with Meffert
technique for ailing implants*
·
Osseous graft placed to cover all
exposed threads (resorbable membrane recommended under flap before closure to
allow better organization of the osseous graft)
·
Close with resorbable sutures (PGA
recommended)
·
Check occlusion
·
2 week suture removal
·
PA radiograph with reproducible bite
on holder at 8 weeks to verify new bone level
·
Recall 3 months
·
Supplement home care with:
o
CHX rinse
o
Brush on FL2
o
Doxycycline 20mg 2x daily till next
recall (Periostat or generic equivalent)
·
Bone Loss with presence of
inflammation and mobility to fixture
Poor prognosis,
implant needs to be removed and site grafted before new fixture
be placed.
·
Implant Complications &
Intervention
§ Peri-implantitis defined as the presence of inflammation with or without
bone loss at an implant fixture.
·
Unless the inflammation is controlled
bone loss will progress with eventual failure of the fixture. Watching and waiting only demonstrates
increasing bone loss and a more aggressive approach is needed to stop the
ongoing process
§ Ailing vs failing:
·
Ailing implant is defined as an
implant that has some bone loss and inflammation but the absence of any
mobility to the fixture with sufficient bone level to maintain the implant long
term if the bone were to remain at the current level
·
Failing implant is defined as an
implant that has mobility and/or sufficient bone loss that long term stability
can not be maintained
§ Criteria for failure
·
Presence of any mobility to the
fixture (need to differentiate fixture and prosthetic mobility) signifies a
failing implant
·
Insufficient bone support to manage
the occlusal loads present
·
Loss of bone level creating an esthetic
issue that can not be grafted to restore the implant to proper esthetics
Avoid:
o
Air polisher (may cause air embolism
due to weaker connective tissue connection then found around natural teeth)
o
Probing (can inoculate bacteria into
sulcus due to weaker connective tissue connection and lack of fiber barrier
allows probe to penetrate till bone encountered giving false reading on pocket
depth)
o
Stainless steel instruments (harder
then implant surface will gouge the implant surface leading to rougher area
which will trap plaque)
o
Ultrasonic/piezo tips (the metal tips
will gouge the implant surface, if used should have plastic tip)
*Meffert Technique for Ailing
Implants
o
Flap tissue to exposure all
supracrestal exposed threads on the implant
o
Remove all granulation tissue on the
implant surface using titanium scalers
o
Detoxify the exposed implant surface
§ Make paste from a capsule of Doxycycline (add drop or two of saline to
make paste)
§ Apply paste to implant surface only (acidic so avoid contact with bone if
possible)
§ Allow to sit 1 minute then rinse
§ Repeat two times
§ Apply citric acid gel to implant surface and bone
§ Allow to sit 1 minute then rinse
§ Repeat two times
§ Modification may be to apply ozonated water to rinse and ozonated oil to
the implant surface as final treatment
o
Site is ready for grafting
Dr. Kurtzman is in private general practice in Silver Spring,
Maryland and is a former Assistant Clinical Professor at the University of
Maryland, Department of Endodontics, Prosthetics and Operative Dentistry. He has
lectured both nationally and internationally on the topics of Restorative
dentistry, Endodontics and Implant surgery and prosthetics, removable and fixed
prosthetics, Periodontics and has over 250 published articles. He is privileged
to be on the editorial board of numerous dental publications, a consultant for
multiple dental companies, a former Assistant Program Director for a University
based implant maxi-course he has earned Fellowship in the AGD, AAIP, ACD, ICOI,
Pierre Fauchard, Academy of Dentistry International, Mastership in the AGD and
ICOI and Diplomat status in the ICOI and American Dental Implant Association
(ADIA). Dr. Kurtzman has been honored to be included in the“Top Leaders in
Continuing Education” by Dentistry Today annually since 2006. He can be
contacted at dr_kurtzman@maryland-implants.com.
Go to www.dentalgirl.net to see more Bios and Protocols of Dental Experts...
Happy 4th Everyone!!
