To Probe or Not to Probe? Implant Maintenance Demystified

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. Even though millions of patients have successfully been treated with dental implants, some of us are still not sure if it's okay to probe an implant. To help us answer some of these questions is our guest, Jessica Woods. Jessica is a registered dental hygienist with a master's in public health. She has spent the last decade as a clinician, speaker, author, mentor, and public health advocate. She is also a past president of the Nevada Dental Hygienists Association, recognized as an oral health champion, and the recipient of the Nevada Dental Hygienist of the Year Award for advocacy efforts and expanding opportunities for dental hygienists. Jessica, thanks for joining us. Hi, Phil. Thanks so much for having me. Before we demystify implant maintenance, let's begin with a pretty basic question. What are the key similarities and differences between implants and natural teeth? Well, the purpose of the implant is really to, you know, mimic the natural tooth. But there are some key differences. Starting at the root, obviously, the implant acts as a prosthetic root. And then we build on top of that with the abutment and the crown. So the attachment is going to differ from a natural tooth to an implant. Those changes are, or those differences rather, are important for us to understand when we're maintaining dental implants. Things like how the sulcus is attached, also things like biological width, all of those things contribute to the inflammatory response when there's introduction of biologics like bacteria and things. Right. So for this particular podcast episode, we're really focusing on what the hygienist does, correct? That's correct. Okay. So what does the hygienist need to understand about the biologic width and the sulcus and the junctional epithelium that exists in a natural tooth, the whole attachment apparatus as it is in the natural tooth versus an implant that's fully integrated? What's the main difference biologically that's relevant to the hygienist? And then we'll get into probing and so forth. Yes. So as far as the root, you know, on a natural tooth, we have the gingiva, the bone, the cementum, as well as the PDL. The periodontal ligament is not present on the side with the implant on the implant. So that plays into the load and understanding that it's always good practice to be checking the occlusion at your hygiene visits to ensure that. There's no high spots. And then if there are, making sure that you're informing the doctor about that. The other thing about the attachment is when it comes to the sulcus, we're used to having the connective tissue oriented in a perpendicular fashion. With the implant, it's going to be more in a parallel fashion. So it's not really a true connection of the sulcus. It's going to be more of a suction where a lot more contaminants. get in those areas so it's important for us to understand that so we know how to manage it and also relay that to our patient with when it comes to home care concerns yeah so when we get into implant maintenance you know we've had 10 solid years or more of putting in over 3 million implants a year. So we're looking at 30 million plus implants floating around out there right now in this country. You know, statistics show that mucositis is basically around 50% of the dental implants versus peri-implantitis, which is anywhere from the research is showing between 12 and 43% and it varies. Is that something that's important for the hygienist to understand and also the dentist, the difference between mucositis and peri-implantitis? Oh, most definitely. So if we relate it to a natural tooth in the way that we grade things there, the peri-implant mucositis is going to be that first degree of disease that's happening. So that's marked by redness. We might see some buildup in the area. But at that point, much like gingivitis, it's still irreversible. We can treat that inflammation. There's no bone loss that has occurred. But as it is left untreated or continues to progress, that's when it... into the peri-implantitis where we're starting to see that marked bone loss and things start to become irreversible. Right. You mentioned irreversible with mucositis, but it probably meant reversible. I think you mentioned it. I did. I did. Apologies. Right. So we caught that. We caught that one, Jessica. So we're paying attention here. It was a little test for you. Yeah, you were testing me. I know. When we talk about... uh instrument materials around implants we've heard a lot about as i said it's been implants have been around a while but we still have that controversy about the type of material we should be using to probe an implant yeah just to elaborate um more on that uh you know when i when i first started out working with implants, all these plastic scalers were very popular. Now we're starting to learn more about the possibility of the plastic scalers actually leaving residue behind that can be harmful to the implants. thought is that these graphite or titanium instruments are far superior. Even some of the ultrasonic tips that we've seen that come with a plastic sheath on top of it, you know, you want to just be mindful that sometimes these microscopic particles can actually be left behind around the implants and that can lead to some complications as well. So when we talk about using metal probes, I assume titanium is acceptable and we'd want to stay away from stainless steel? Yeah, so ideally you would want to use titanium, as you mentioned. And then there are some other products or materials that are available as well. As far as instrumentation, we have products like PEAK, which is PEEK, polyether ketone. And so that is a very resilient type of material that hasn't been shown to... leave any shedding behind there. And then there are some harder plastic probes that are adequate to be using around those implants as well. Do you have any particular products you could name for our audience just so they're familiar with what their choices are as far as maybe the hard plastic and also the other material you mentioned? Yeah, so as far as hard plastic, the two that I'm most familiar with is there's one from Hugh Freedy. It's this bright yellow probe. And then also Premier has a nice Periowise probe. The one thing that I really like about the Premier's Periowise probe is the markings on it. So they actually have green and red markings. So it helps to visualize, you know, if you're in the green, that means you're good. If you're getting into the red areas, then you know that, you know, there's marked attachment loss there. Is the Periowise probe that you're talking about for implants the same probe that you would use for natural teeth? Yes. So that's the great thing about it is it's used for both natural teeth and for implants. And so it doesn't require you to switch over probes. You can use the same probe as you're going through the mouth if there's just a single unit implant in there. As far as the implant scalars are concerned, there's, you know, some... companies that put together nice kits. There's quite a few of them on the market where they'll have a nice kit put together where they have a few different scalers all together in one. And then as far as the ultrasonic, which I'm a big fan of, especially around dental implants, because really you're not going to see a lot of hard calculus built up. A lot of times we're just trying to disrupt the biofilm. And so ultrasonics are great in this application to get the water down there, disrupt the anaerobic bacteria. And so the one that I really like as well is from Premier. It's called the Big Easy. And that one has that peak material, the sleeve on it. So it helps, you know, it's good to use around implants, but it's not going to leave that residual plastic behind. And that's called the Big Easy? Yes, that one's called the Big Easy. Okay. And that's used the same way we would use a typical ultrasonic tip? Yes. So it functions very similar to a regular ultrasonic tip that you would put in your ultrasonic unit, not to be confused with piezo, but with your ultrasonic. And then it just has a special sheath on it that's made of that peak material. So now it makes it safe to be used around implants. Okay. So how important is it for a dental hygienist to really understand the biomechanics of dental implants? And I'm referring to the structure, the form and function of an implant. Yeah, so, you know, I think a lot of times, you know, maybe the hygienists don't see how this could be, you know, relevant and might be, you know, thought that this is just important things for a dentist to know. But I know for, you know, my personal experience in the management of dental implants that really I was able to... grasp a stronger understanding once I understood the bio the biodynamics of implants. So things like the emergence profile of the implant. Sometimes, you know, we see that it just looks like what we say is a pumpkin on a stick where you see the implant and you're going to have this very bulbous crown. That's obviously going to be harder to manage hygienically both for you and the patient. So understanding, you know, the different designs of implants, their emergence profile, the way that that abutment comes off of the implant. And the other important thing is a concept that we call platform shift. And a lot of implant companies now today, this is back. by science that they basically, you want the diameter of the abutment to be smaller than the diameter implants. You almost have this little lip going up from the implant to the abutment. And what this does is it helps with the micro leakage. And so we found that having this design on the implant actually helps to preserve some of that crustal bone. And so we're not seeing as much bacteria micro leakage or bone loss in that area. And so understanding these types of things like biodynamics, as well as I mentioned earlier, occlusion is very important as well. Our teeth are living, they move, things change. So when the implant is put in, You know, things can change over time, and so the occlusion can change as well, and so that's why it's important for us as hygienists to be aware of that and make sure that we don't want to have too strong of an occlusion on that implant because it can bear too much force when the patient is chewing or biting, and that can actually lead to implant failure. Yeah, I was going to ask you, what are some of the typical symptoms that you would see as a hygienist in a patient that has a very strong occlusion on a particular implant? The best way to identify is by using some articulating paper. If you see a lot of bite contact there, that's a really good thing to draw to attention, especially when the dentist comes in to do the exam, so that way they can do any adjustments necessary. It's a good practice to always have a piece of articulating paper there waiting and do that regularly as part of the re-care exams. So are you seeing a large swath of people coming back to their dentist after having implants placed previously in previous years where they have mucositis and peri-implantitis? Are you seeing that as a fairly prevalent condition? Yes, it is very prevalent, much like periodontal disease. You know, we're seeing about the same rates. A lot of times the reason that patients need implant... is because of a periodontal issue. And so unfortunately, habits don't always change. And so just like the management of their natural teeth. They're managing them the same way as the implants, and then that's when we're running into having issues. So it is very prevalent. We're seeing it just as much as periodontal disease. As far as the literature and things like that, really the verdict is still out. It's kind of all over the board. There's still a lot to learn about perimucositis, peri-implant disease. But, you know, what we're seeing in practice is that it's very common. A lot of times, you know, patients are afraid to touch it, maybe haven't been properly educated on how to care for it. And then also, you know, itrogenic factors like the biomechanics of the implant. You know, maybe it's not the desired emergence profile. Home care, you know, using wax floss, just like plastic, the wax can leave behind particles there as well. And maybe the patient doesn't. do that. And so there's some environmental factors happening there. So when it comes to longer implant abutments, should a hygienist expect deeper probing depths that correspond to a longer implant abutment and then just kind of measure the difference between the visits and say, okay, you know, we've moved from this many millimeters to this many millimeters, whereas typically on a natural tooth, if you exceed, you know, four to six millimeters, you've got something to worry about. Yeah, that's exactly correct. So on a natural tooth, anywhere from one to three is what we're considering healthy, and anything above that would be indicative of disease. Whereas in dental implants, typically you don't want to start probing the implant until... six months after the final restoration is delivered. We want to make sure that we're allowing for proper osseointegration, letting everything heal before we go in there and disrupt anything. So after that six month mark is when you're going to want to establish your baseline. And it's just that that's the baseline that you're going to use for, you know, three, six, 12 months down the road to detect any changes. An implant can actually be still considered healthy, even with four or five millimeter probing depths. It's going to be that marked change, the bleeding on probing, using your radiographs to detect changes in the bone as well. So exactly right. So getting back to the title of this podcast, Probe or Not to Probe, what kind of recommendations as a summary would you give to hygienists about probing an implant? You know, that's kind of the age-old question to probe or not to probe. And, you know, current research does support the benefit of probing, that it is necessary. We want to assess, you know, the presence of bleeding on probing. We want to monitor those depth changes. We want to see if there's been any migration in the... mucosal margin so all of that is very important and we have to do that with a thorough periodontal evaluation which includes probing around the implants as i mentioned there's a lot of or there's quite a few implant specific probes on the market and so you know those are are great tools to use there are you know some metal versions as well as some plastic That's not as concerning as using the plastic instruments where we're actually engaging on the tooth structure and going up and down where there could be. you know, debris left behind. As far as the technique goes, you know, you want to follow the same technique as far as the sites that you're probing. So you want to do your mesiodistal, your buckle, your distal buckle, your mesolingual, lingual, and distalingual. So the six measurements you're used to normally doing. And then the technique is just slightly different. So on a natural tooth, we're used to, you know, placing the probe angled into the sulcus, whereas on an implant, the probe is going to be more parallel. with the implant. You'll want to use a gentle pressure. As I mentioned, the sulcus, you know, it's not true attachment. It's more of a suction. And so if you place too much pressure, you can actually, you know, violate that biological width that's there. And the probe can, you know, if you're putting too much pressure, it can... look like a pseudo pocket, that you're creating a pocket that's not actually there. So just a light, gentle pressure that's parallel to the implant connection. And again, just to reinforce one more time, really what we're looking for is any changes from that baseline, the bleeding on probing, inflammation, any exudate, anything like that. And so it does take a little bit of a thought shift with how we're... you know, used to probing as well as a lot of times you just have one implant in the mouth. So you're having to change your technique from the natural tooth and move over to the implant. So it does take a little bit of practice and special care. Jessica, we appreciate your time and your expertise. You certainly have been in the field of dental hygiene for a while as far as your knowledge and education. And as I mentioned in my introduction to you, you were past president of the Nevada Dental Hygienist Association. Are you still involved in Nevada? I am, yes. I still sit on the board of trustees for NDHA. I'm currently spending most of my time as our state delegate for the National Association, as well as on the legislative committee. One passionary of mine is advocacy around advancing career opportunities for hygienists. You don't spend too much time in the casinos, I hope. Not too much. Only when it's hot out and we need free air conditioning. Yeah, there you go. Yeah, I know. The heat that you're having there is incredible. It's triple digits, just like it is here in Austin, Texas. I mean, we've had weeks of over 100 degrees. I know you guys are hitting 110 plus. Yeah, I think we just hit one of our records for the year. We were at 117. Wow. a while since we've hit that hit that high but yeah i just visited austin a few weeks ago and it was you know no break from being in in vegas either it's just an extension of las vegas without the casinos exactly Yeah. Enjoy yourself. Stay cool and bet red, I guess. If you do go to the roulette, I usually bet red, but I'm only kidding. I'm not one that you want to follow as far as gambling. I don't do very well. So again, thank you so much, Jessica. We'll look forward to having you on a future podcast. We'll get more information out of your expertise in dental hygiene. Thank you. Thanks, Phil. Thanks so much for having me. 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