Implant Maintenance Update: New Evidence, Better Outcomes

Stainless steel left behind is not biocompatible, and what we're finding is metallosis inflammation caused by shards of the metal ions being left behind. So we're finding the metal ions are in the biofilm, the metal ions are being engulfed in the soft tissue. Welcome to Austin, Texas, and welcome to the Dr. Phil Klein Dental Podcast. Dental implants have transformed restorative dentistry, but placing an implant is only the beginning. The real challenge and the key to long-term success is proper maintenance. Yet many clinicians are still relying on protocols they learned years ago, despite growing evidence that some traditional techniques, instruments, and even preventative products may do more harm than good. So what should today's implant maintenance protocol actually look like? Joining us is dental hygienist Lynn Pencek, who brings a unique combination of clinical experience and industry expertise. Lynn is passionate about helping hygienists and dentists cut through the confusion surrounding implant maintenance with practical, evidence-based guidance. In this episode, we'll explore why implant maintenance remains such a misunderstood topic. Uncover the truth behind metallosis and tribal corrosion. Discuss how instrument and polishing choices can impact implant surfaces. Examine the surprising relationship between fluoride and titanium implants and reveal the modern protocols every practice should be implementing to help ensure long-term implant success. Before we get started, I'd like to thank all of you for tuning in. If you're enjoying the show, please follow us on Apple Podcasts and Spotify, and even better, leave a review. By doing so, you're not only showing support for what we do here, but your reviews are instrumental in getting more dental professionals to listen and benefit from our content. We really do appreciate it. Lynn, it's a pleasure to have you on the show. Phil, thank you so much for having me. Yeah, thank you for your contributions over the years, what you've done on Viva Learning, some really nice presentations. And for our listeners, if anybody's interested in listening to or watching a really good webinar or a couple of good webinars by Lynn, just look up PENCEK. It's spelled P-E-N-C-E-K on VivaLearning.com. Just put that in the search box and you will find her webinars, which really are very well presented and comprehensive in the areas that we're going to be talking about today. Lynn, before we get started, I just want to give the audience a brief overview of where we are with implants and the two perio implant conditions that we'll be talking about today. Some basic facts, 5 million implants are placed annually, which is just a whole lot of implants, and that's just the US. 3 million Americans have one or more dental implants, just to give you an idea. um of that group according to credible sources pubmed and others peri -implant mucositis affects 45 to 63 percent of those patients and that as we know is is a reversible condition somewhat like a gingivitis and then we have peri-implantitis and that affects about 12 to 18%, some are saying 20%, which is one in five, and that's concerning. And as most of us know, periimplantitis is the progressive form that includes bone loss and can lead to implant failure. So the bottom line here is that roughly half of the patients with implants have periimplant mucositis, which we could detect early and get on that quickly so it doesn't progress. And roughly one in five patients have periimplantitis. So having said that, I want to bring up something that you've said often in your webinars, actually. And I know you talk a lot for some major companies. You're becoming a very well-respected and well-traveled lecturer in this field. You say that one of the biggest problems in implant dentistry isn't placing implants so much. It's maintenancing them. It's maintaining them. Why do you believe dental implant maintenance has become such a misunderstood area of clinical practice? Bill, thanks for asking that question. When I was in dental hygiene school, and that was early in the 80s, we received an hour of lecture time. And I left that curriculum with the message of these are implants, they're new, they're being done a lot in Europe, use plastic instruments. And back then, that's what we did. And I found it interesting when I started this project, I'd have a lot of people, you're talking about implants, you use plastic instruments, right? And when I did my transition of working from a salesperson to going back to clinical in this project, I did a lot of temping because I wanted to know what's going on out there. And I was floored how many times I saw plastic instruments in offices. And we've known for a very long time that this is not the method. Yeah, number one, it doesn't clean as well, obviously, because it's plastic. It's a biofilm. What's plastic going to do? Right. It doesn't do much. And on top of that, plastic particles come off of that and tell us what happens with those plastic particles. We've been reading about that in the news. It goes everywhere, but it's certainly not helpful in the periodontal area. The visual I like to give is the implant surface is rough. So let's take an emery board. And take a plastic instrument and drag it across and you're going to see little tiny particles of the plastic left behind. The plastic's not biocompatible and it will hold in biofilm and it'll contribute towards inflammation. So we know that's not the way to go. My concern with dental hygiene education is their curriculums are packed. I mean, that is a solid two-year curriculum in order to graduate and take the board exams. And most of the patients we see in dental hygiene school have natural teeth. very few implants but we will find some patients who had implants that now will go to a hygiene school or a parent of a student in school may show up in a clinic with implants we get very little experience in hygiene school and there's no mandatory continuing education to keep us up to date yeah and one of the things this is the same problem in dental school with other areas like laser therapy they get very little training on lasers some dental schools don't even have any because the curriculum is so packed and there's so much but The thing with implants is that, you know, when we first started putting implants in, we didn't have enough years to track, you know, what the ramifications of poor oral hygiene is with implants. We know that it works by ankylosis. There's no PDL. There's no cementum. So we understand that. But we really looked at the success of implants as it's almost like they're indestructible. Like they can't break down. And then as the years went by, we started to realize with so many implants being placed every year. And it's only 12 to 18% that fail. So you can see many patients with inflammation. And here's the thing about the disease that's interesting. You can be inflamed and be pretty stable with the bone levels for a period of time. And then it rapidly breaks down. And you'll see someone come in that's been maintained for a while. And then they come in and there's rapid bone loss. Right. And there's nothing worse than having to tell a patient that your implants are failing. Let me ask you about your experience with Nobel Biocare. How did that experience open your eyes to the communication gaps between oral surgeons, periodontists, restorative dentists, and hygienists, of course? And why does that matter for long-term implant success? This is a great question. When I was working as a rep, I would visit my accounts, and if implants failed, we would write a report. I'd be given the implant in an autoclave bag with the patient's name, and we'd ask, when was the implant placed? What was the surgical technique? How old, how new were the burrs? Did you have proper irrigation? What was the patient's risk factors? And the surgeon, Dr. Sam out of Princeton, said to me, I would place these implants, and then I don't see this patient again for 30 years. And the implant failed. And he wanted better communication with the restoring offices. was aware of is you'd have a restoring office with a patient with inflammation and they bring the patient back in six months hoping it would look better later and so i was learning that this communication wasn't transferring well between the specialties me as a hygienist and that's very important because there's no way for us to understand how to solve the problem if we don't really understand how big the problem is how prevalent it is what kind of cases are failing yeah that's not good so what did you do what did you do about that You know, the surgeons would show cases to hygiene classes. We bring a surgeon in to speak about implants and they'd show the surgical case. And we as hygienists are just like, this doesn't apply to what we do. It makes no sense to us. It doesn't value. And you'd be, you know, you're not interested in the class. And, you know, when I talk to hygienists, they want to learn how to scale implants. And when I hear, how do you scale implants? I'm like, no, the key here is we're supposed to reduce biofilm. So we don't have to scale the implant. I mean, if you want to maintain the implant healthy. We shouldn't let the calculus. Yeah, see, that's the myth, which is really important that you pointed that out, is that hygienists and dentists believe, because they've been taught this in dental school and it's in their culture of preventative dentistry, preventative dental hygiene, is that you have to pick up a scaler and you actually need to scale. But when you're working with an implant, the idea is not to even get that far. And even if you need to get that far. There are other options other than using a scaler. And let's get into some of those other options. And we don't have this formal education for dental hygienists right now in the curriculum, like we mentioned. So there's some huge knowledge gaps there. So when you see a pain, let's start with mucositis. What is the current way of looking at that condition and treating it today? So this is inflammation. normally caused by biofilm, but it might not be. There's other reasons. And that's where hygienists need to understand there's other reasons besides just poor home care. I honestly think your biggest tool in treating mucositis is disclosing solution and identifying where the biofilm is, educating the patient, removing the biofilm, and then reviewing home care and bringing the patient back in two weeks to see if the mucositis results. Now, what's the best home care for a patient that has this power toothbrush? Is a water flosser good to use? Is there anything mechanical? I'm a huge fan of water flossing. String floss has got a very interesting mixed reputation in the community. We have people very, yes, you must floss. And some people who are very, no, never floss. It leaves shreds of floss behind. Are you talking implants or just generally speaking? Implants. Okay. Implants. You'll see there's some people really don't want to see floss on implants. And you'll see people who say that is the best way to treat it. It can get caught in the threads. That is when you really don't want to be flossing. If there's exposed. rough the implant surface is rough it's got that nano rough surface texture to it and the floss if it's woven can shred and leave pieces behind so if i do have floss on implants i want something that monofilament something that just breaks clean in half okay so you have mucositis peri-implant mucositis they come back would you say Two months or two weeks? Two weeks. I want to see it result in two weeks. And then they come back, not really, let's just make this up, not a major dramatic change, even though they're doing what you're saying they should do and they're claiming that they're doing it. What's the next step in the office? If we're still inflamed, we really should be looking at the patient's risk factors and seeing what other causes could there be of inflammation. What kind of meds are they taking? It could be hormonal. It could be traumatic occlusion. So I'm actually, I'm recommending blue indicating tape. So do you honestly think that in two weeks time, if it's really not anything more, it hasn't progressed further than mucositis, that it should look a lot better in two weeks if they're really complying at home? If they're compliant. Okay. Now let's talk about the patient who just moved to the area. They had their implants done in a different city. They're in your chair, in the hygiene chair, and you notice you see some threads in that implant. There's bone loss. There's bleeding on probing. So this looks very obvious. Yeah, very different. And the patient even says this is kind of progressing in a fairly quick manner. So you're pretty sure that you're looking at something more than peri-implant mucositis. So what's the first thing a dental hygienist should do in this case? And this depends on what tools you have in your office. So we talked about the plastic scalers. Air polishing is a very effective tool. and removing biofilm. And there are subgingival airflow tips. And if you have the right tools in your office, you can give it a good go. Bring the patient back in two weeks to see if the inflammation and the bleeding has resolved. The expectation of regrowing bone is not likely, but I do have friends who work with a periscope and very few hygienists work with periscopes. They've been around 30 years. I'm just now seeing fantastic momentum. And I know a hygienist who... with desiccation therapy, works with biologics, works with the periscope, and she's regrowing bone without opening a flap. She's the exception, not the rule. And you could use some laser therapy for possibly decontamination and hopefully get some regenerative bone. I'm licensed in two states where I just can't use lasers. But I mean, without sending it to a periodontist, what is the chances that just using airflow could stabilize something if they are... complying at home. Is it pretty good if it's in the early stages of peri-implantitis? A hygienist can maintain early peri-implantitis with the right tools. Do you recommend them sending it to a periodontist just from the standpoint of protecting themselves? I do. For communication, second opinion, absolutely. And I'd like to see a letter with a photograph. a radiograph and a dialogue patient presents these are the tools we have in our office are you comfortable with us keeping the patient here would you like us to refer to you yeah that's a very that's a very good approach and that's not done enough i mean that really because you let's see what happens in six months so what's the discussion with the patient when you're Planning to write that letter or that communication. Nobody writes letters anymore, but that email to the periodontist. And you say, here, these are the tools that we have. Just what you said. This is what the condition of the patient. This is the radiograph. What's the conversation with the patient that hygienist should have or that dentist should have knowing that he or she's going to do that? Yeah, they're a new patient coming from a different office. I like to understand where they are in their understanding of the case. And if they've been told everything is fine. Start asking questions if they picked up on any symptoms, if there is any soreness. Are they aware of any changes? And that may make the dialogue easier. I have no idea what you looked like before. We do not have pre-existing x-rays to compare year over year to look for changes. But this is what I see today. And this is what I am concerned about. And making sure the patient understands and owns their case is very important. There was an article. A couple months ago, and it was a patient who had full mouth reconstruction and then did not go to a dentist again for 25 years. And the x-rays in that article were mind boggling that the bone loss went down around the apices. And when you read the article, the patient was given the option to have the prosthetic off, take out the failing implants, decontaminate. I mean, they went through the whole treatment plan and the patient opted to leave the prosthetic on and just clean around the implants. And it's, you know, this patient does not understand. And this is where we were early. So the key thing is informing the patient what's going on and what you want to do. And of course, documenting everything. Now, you talked about airflow. What's the difference between the treatment of a... who has peri-implantitis that's already been treated by a periodontist and the periodontist has done the best they can. Now it's up to the hygienist to maintenance that implant. Do they still use things like glycine and erythritol airflow for that? Glycine and erythritol are the medicaments of choice. What does the evidence say about using baking soda? There's articles about baking soda airflow or baking soda air polishes removing the SLS coating. certain implants. There's articles about using baking soda, sodium bicarbonate with air polishers on implants contributing to corrosion because it's extreme in the pH scale. So the erythritol and the glycine are the two medicaments of choice, biocompatible, neutral pH, reducing bacteria. One reduces red spectrum bacteria better than the other. And what about desiccation therapy? That's kind of new. Desiccation therapy is kind of an interesting topic. So this is the, can I use brand names? Because there's two brand names. Okay. Okay. PerioDT and HybenX. HybenX is the manufacturer of PerioDT. They are the same product, two different distributors. So desiccation therapy is the removal of the water from the biofilm. And it will, studies show it will clean out the red spectrum bacteria for a few years. How do you apply that to the pocket? So this is a gel. It comes in two forms. It comes gel or liquid. I look at it like gel, supergingivally, liquid, subgingivally. You're applying it for 10 to 30 seconds and no longer. It's rinsed off and you'll find that the calculus comes off so much easier. And what it's doing is it's disinfecting the pocket. So if I have a patient, edematous, lots of bleeding, it also has a hemostasis quality to it. Does it obviate the need for scaling? No, you still have to scale, but it's going to make the scaling process much easier. That's interesting. So could you use airflow after you put this desiccant in? There's a 10 second method, 10 second application of the desiccation therapy. And in this article, they use the baking soda in an air polisher. So when I'm teaching my class, I bring up this article and it goes against everything I've talked about because I'm saying neutral pH, don't use baking soda. And then I'm saying use both in this article. The study is in vivo. I'm sorry, in vitro. It's in glass. It's not done on humans. It's done on implants outside. And implants are clean. So in my theory, the way I see this, when I have that active patient, I think this might be a good thing to be doing. It's still new with implants. I think this is a good thing. I'd like to see more of it tested and written upon. There's concern that it might cause corrosion, but we're not. It's the Wild West out there, Phil. I'm not 100%, but I think it's a good thing. And that guy, the guy who didn't show up for 25 years, I'm going to use it on him. If it works on him, then you know it's going to be good. So what's interesting is the more I read about this conundrum. the hygienists are in when it comes to what to do when you have peri-implantitis. There is no one silver bullet. It depends is the answer. But what we know we shouldn't do is use stainless steel scalers for sure. And that's where we get, you know, metallosis and tribal corrosion. Talk about that for a minute. These are the things we know we should not do. Shouldn't be doing. So there's studies demonstrating it doesn't matter what instrument you use. on the rough surface of an implant, plastic, graphite, stainless steel, titanium, all will leave some residue, residual of the instrument on the implant surface. So the titanium is biocompatible. So if we're using titanium on titanium, whatever's left behind is considered biocompatible and safe. Stainless steel left behind is not biocompatible. And what we're finding is metallosis inflammation caused by shards of the metal ions being left behind. So we're finding the metal ions are in the biofilm. The metal ions are being engulfed in the soft tissue. This is that endocytosis you're talking about. Yes. So just so our listeners know, endocytosis, particles that are being left behind that Lynn is explaining actually goes into the cell via the cell membrane. And that could cause what? Some sort of autoimmune reaction or inflammation. Inflammatory response. Right. And that just exacerbates everything, right? Yeah. Correct. Yeah. Then you're looking at inflammation on top of inflammation, which is not what you're, that's not your goal. So we certainly want... Going in with best intentions and you're causing a problem. Yeah. So if you're going to use a scaler, they have these anodized scalers that have this titanium oxide on top of the titanium, which gives it even more protection. Is that something you recommend? Because the anodized surface is like a thicker... natural oxide layer. It doesn't sharpen the scaler, but it improves the surface properties so that it doesn't break off little pieces. So you're seeing it in the implant. So the anodization makes the implant more biocompatible. The dental hygiene instruments are being anodized. I like the color indication. I like to be able to say the purple tipped instruments, what I use on my implants, the stainless steel for the rest of the teeth. So it gives me a quick identification. Right. That you know that's what it's for, you know, using it for an implant. So if you would, Lynn, put on your hygienist hat for a second. Is there a difference between the force used when hand scaling an implant versus hand scaling a natural tooth? Depending on where you are on the implant, you have the smooth surface of the abutment with soft tissue attached to on a healthy implant or mucositis. I find the calculus comes off pretty easy when and if I find it. I personally do not come across a lot of calculus at the smooth surface of the implant. But if it's in the threads, it's a totally different game. And I find I'm using more of a tipped instrument, not a curette. A curette on the smooth surface. A curette doesn't fit in the threads at all, in my opinion. I find it's a horizontal stroke in the threads. You don't want to do a vertical stroke because you'll damage the threads. Is it more resistant, the calculus on an implant when you have this fairly advanced peri-implantate? It's part of the access. It's what? It's not harder to come off. It's more awkward and harder to access. I see. Because it's just the nature. It's the nature of the threads in the implant. Yeah. Yeah. And usually it's lower linguals, which are hard to reach anyway. I'm falling in love with this one manufacturer's TAs on tips that are just longer, thinner, right and lefts. What company is that? So Action makes those. Yeah, that's a good company. I'm a big fan of the straight tips, Hugh Freedy's and Premier's peak tip. They have a white tip, so you know it's peak. You know it's biocompatible on straight implants on the abutment of the implant, if I have a mucositis case. So what I'm saying here is one size does not fit all. So it's good that we have in our dental hygiene armamentarium a good selection of tools that we could use to combat mucositis and when it gets worse, implantitis. But I think the bottom line is, and I think you've reinforced this notion throughout this podcast episode, is that you need to keep communication open with the periodontist, especially in the beginning when you see that you're in a state where things could really go south if you're not careful. do the communication first. And the reason is you could have a five, seven millimeter pocket on an implant and still be considered healthy. And we as hygienists are programmed three millimeters and under is healthy. So the periodontist doesn't want you to send that five millimeter pocket to them because they don't want to say to the patient, you're fine. So that dialogue first, and you do the best you can with what you have in the office, have that dialogue, let the patient know that the periodontist would like to be, would like you to visit. or the periodontist will tell you you're fine at the office and keep that dialogue. That difficulty in assessing, what do I do when it's mucositis? What do I do when it's early peri-implantitis? Right. So Lynn, when it comes to actually polishing the abutment, that's important to remove the biofilm on the actual abutment because we don't want to have that build up and move into a mucositis. What are the restrictions on that? Can we use a rubber cup with any prophy paste? There's lots of articles supporting rubber cup polishing with prophy paste to remove biofilm on healthy implants. mucle attachment on the abutment it was funny when i started this project i was in my brain i was poo-pooing the rubber cup and that was me not defining the difference between polishing the crown and polishing where the threads are exposed so if we have a healthy implant you are fine with a rubber cup polisher. But if the threads are exposed, what's the restriction? Then we want to go into airflow. The airflow will get into the threads better. Okay. So let's talk about fluoride. It's always been considered one of dentistry's greatest preventive tools, yet it can also contribute to corrosion around implants. So how can something that's so beneficial for teeth become a concern for titanium implants and what practical steps can clinicians take to reduce that risk? So when implants are manufactured, they're creating this corrosion layer on the outer surface of the threads of the implant. And one of the methods to create the corrosion layer is with fluoride. They're using a hydrofluoric acid to create this layer. So we know fluoride in an acidic environment can cause corrosion to the implant. So I kind of break it down. There's good corrosion. There's bad corrosion. We want the corrosion for osseous integration. After the implant's placed, we don't want to cause corrosion to the implant that's exposed. That rough surface will attract biofilm. Yeah, that's a very good point. So when we have a patient that has implants, but they also have natural teeth, and those natural teeth would benefit greatly from fluoride because they may be high-risk caries patients. And we don't want to, like you mentioned, introduce fluoride into an acidic environment because it becomes corrosive. And we don't want to... any corrosive activity on any exposed threads of the implants that do exist in their mouth. What are our alternatives? What do you suggest? I look at this as an equation, concentration, frequency, and pH. Over the counter, fluoride toothpaste has a low concentration and you're only using it twice a day. Over the counter, fluoride toothpaste are safe to use on implants. High concentration prescription fluorides. are usually given to a patient for the high caries rate, probably has more of an acidic pH in the oral environment. And then they're putting a high concentration fluoride gel daily. So now I have a high concentration, a high pH frequency. That's where I'm concerned about the fluoride causing corrosion. That's where I'm concerned. So my suggestion is instead of sending the patient home with a high concentration fluoride prescription, if they're coming to see us three, four times a year, After we're done providing our oral hygiene services, the environment's probably going to be neutral and you can apply a neutral sodium fluoride in a neutral environment and it won't damage the titanium. So my thought is move in the direction of fluoride varnish as opposed to daily home prescription use. Something like VOCO's profluoride varnish is a good choice. And then we can take it one step further and we can go in the direction of hydroxyapatite instead of fluoride. Because we're seeing patients' preferences are moving away from fluoride and we're going more in the direction of hydroxyapatite is a good option. You have a patient mixed dentition, natural teeth, high caries rate with implants. And instead of sending them home with a high concentration fluoride prescription, we can send them home with a concentrate of hydroxyapatite, a hydroxyapatite cream such as Remin Pro by Vogo. And in this case here, we're not giving that additional exposure to fluoride. We are giving the patient the benefits of remineralization. So it's a good alternative to a fluoride prescription. So if you could update every dental practice that practices dentistry all over the world right now with a modern evidence-based implant maintenance protocol, what are the most important changes you would want dentists and hygienists to implement immediately to improve the longevity of their implant cases? You know, air polishing. In 2020, Ivy Zelmer published an article interviewing 1600 hygienists and asked, what are you using to remove biofilm? How effective do you feel? And in this article, 95% of the people said that they had plastic instruments and only 10 felt like they were, they felt effective in removing biofilm. And in the same study, 10% of the people who filled out the study said that they used air polishing. And 90% felt they were effective in removing biofilm. And in the past five, six years since that study in 2020, we've seen great efforts in the manufacturers of air polishers, really airflow, really educating that this is the proper tool for implants. And so my first suggestion for your question is if the office does not have an air polisher that can work with glycine and erythritol to strongly consider getting one. You got to refer those patients with the threads exposed to a specialist who does. No, very good point. Very good point. Yeah, no, that is the first point there. Assessment. We need to be better trained on assessment. What is the patient's risk factors? How are we going to manage the patient based on what we see clinically and the risk factors? We should be taking x-rays once a year to identify stability of the bone. Early identification and intervention is your strongest way of preventing peri-implantitis. Obviously, it's an ongoing educational journey to stay up on this stuff. And we just have to keep doing that and take CE courses, et cetera, and listen to podcasts and webinars and people like you. Very interesting discussion. Really happy to have you on, Lynn. And we're looking forward to having you do more webinars and podcasts in the future. Thank you so much. I do appreciate this.