Recognizing Implant Disease and What We Can Do About It

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. In today's podcast, we'll discuss how we can recognize implant disease and prevent loss of implants with innovative chairside techniques. We will also address user-friendly oral hygiene practices for our patients to use at home in order to maintain the life of their respective implants. Our guest is Dr. Samuel Low, professor emeritus at the University of Florida College of Dentistry and an advisor member of the Pankey Institute. He is past president of the American Academy of Periodontology and a current officer of the Academy of Laser Dentistry. Dr. Low, it's a pleasure to have you on Dental Talk. Well, thank you, Phil. Good to be with you again. Yes, and I appreciate all your time, and I know how busy you are. It's great to hear that you're still teaching, which is amazing, at University of Florida, your emeritus professor or professor emeritus. which is great that you still have your hands in it. And we have so much to learn from you. I do want to start this podcast with a pretty simple question, but just something to clarify for our audience before we go forward. Is implant disease something we as clinicians should be concerned about? Well, unfortunately, the answer is absolutely. The numbers continue to increase. We're monitoring these numbers for both mucositis, implantitis, which we're going to talk about in a little bit later. But if you talk to periodontists, they will suggest to you that an increasing bulk of their business now is doing nothing but managing implantitis. And at the last AAP meeting, everyone that got on the podium that was a periodontist, some of these folks were running around about 20 to 25% of their entire practice week is trying to reverse implantitis. because unfortunately, the alternative is not good, and we'll talk about that. So we're putting in about 3 million implants a year in that range. We've been doing it for a while. So is this something that's a concern now because there's so many implants in the mouths that are in our patient population? You hit it on the head. The problem is that we've been at this for 25, 30 years, so now the numbers continue to increase. so if you're doing 25 you know 2.5 to 3 million a year and we'll continue to do more the numbers continue to increase which then just creates your odds that things are are going to go astray and there's multiple reasons why that is occurring not to create alarm but it's difficult to determine really what percentage of implants are lost uh we probably come around to five or ten percent but there are some studies unfortunately that are showing from the time of inception to where we are now with all implants, it's running over 20%. Our one out of five implants are actually not diseased. We're actually losing those implants. Yeah, wow, that sounds higher than I would have expected. I was not aware of that number. So tell us briefly, if you would, Dr. Low, the difference between implant mucositis and implant titus. Which is absolutely a critical distinction because it also depends upon who's going to manage it. Mucositis, I call the gingivitis of implant disease. How do you know it? It's red, it's inflamed, maybe a little bit of suppuration. You know it that when you probe around it, you're going to see bleeding. But this is those classic signs of gingivitis. But no bone loss. When you talk about implantitis, it's when you and I both know as clinicians that there absolutely is pathologic bone loss. And let me reinforce that. Every now and then, we have to countersink more apical than we would like an implant, only because I'm trying to find available bone. Well, if we take it further down, the bone is going to follow the abutment. so you'll see an angular kind of thing and you you might say well that's bone no that's not bone loss that's no different as you know with a tipping tooth where the cej goes down versus the tooth next to it the bone goes down but that's not an angular defect you you have to show that it is truly bone loss now at least getting into the first thread or to be implantitis right and so the treatment of these two different conditions are dramatically different and the prognosis obviously dramatically different correct correct there is certain things that parallel periodontitis and there's certain things here that don't we know that gingivitis doesn't always end up being periodontitis we know that there's too many folks that have had gingivitis their entire life and never have very little bone loss because it is host the same thing true with mucositis and implantitis uh folks can have uh highly inflamed implant areas and it not really get into the next core of implantitis the trick is watching it monitoring it looking at it and if i go back which is more important the probing or the radiographs both are important but what's the most critical it's the radiographs The radiographs, the radiographs. And you know, Phil, you kind of have a natural way of determining a depth gauge on the implant more than a tooth because you got threads. So if you look at your threads, you could almost count. So you got like a little automatic periodontal probe on the implant, which on a tooth, it's smooth and it's hard to sort of determine, did it change? Right. So when it comes to implant disease, it would be great if the patient said, to the doctor they called up the doctor and said doc i think i need an appointment because i had an implant three years ago and i think i have implant disease of some kind now that's not really what's happening right because they're not aware of their implant disease just like they have most of them are not aware of their periodontal disease exactly so so the presence of implant disease that's something that has to be recognized by the office so can you tell us a little bit about that exactly actually a study just came well in 2021 And it looked at patients and said, do you have implant disease? And they looked in their mouth. And probably, I think it was right, 90 to 95% of all implant disease was undetected by the patient. They had no awareness of it. And generally, how do they have awareness? It's generally in the interior where they feel a little soreness. And most of that time, it's probably due to minimal attached gingiva or no attached gingiva. But they're clueless. And I'm going to tell you why it's even more important than periodontitis. We now know that implantitis is much more episodic than periodontitis. In other words, periodontitis, once it gets into the moderate to severe, is episodic. But we now know that even in the early to moderate on the implantitis, that it is definitely exponential. It's definitely episodic. I want you to look at both perio and implant, but I'm strongly suggesting that you have got to probe, but more importantly, you've got to take those radiographs because your baseline and where you are now tells you everything relative to prognosis. Are there guidelines now for periodontists and GPs that are treating patients that have implants on their re-care? appointments regarding radiographs to monitor what you just talked about? Because if it's episodic, it's not as linear as periodontal disease, meaning that there's not this long runway or a longer runway where you can catch this and treat it and manage the periodontal disease. You're saying if it's episodic, we're looking at the possibility of a quick degradation of the implant system and the loss possibly of the entire implant. Correct. We are always, as you know, uh trying to adhere to ada guidelines on you know frequency of radiographs but we do know that it's based also just on the clinical and what the radiograph looks like now here's my point if there is no clinical signs or symptoms and your radiograph is sitting right there of where the bone is and you see it year after year after year then you should take it every 12 to 18 months however If you're seeing inflammation and especially suppuration, especially suppuration, and you're already seeing bone loss, then those radiographs need to be taken at least every 12 months. I would not go past 12 months. I would take those radiographs. And you know, the other part is those radiographs have to be good. In other words, you and I both know that a radiograph is not a radiograph. So in other words, it has to be somewhat standardized. You can't have foreshortening because it's going to look like a grew bone or a lost bone. So your team has to be very in tune to taking these radiographs. Now, here is also the point, though. You don't necessarily have to take a PA. I mean, a bite wing, a good bite wing, which is probably the best, would show you where you are versus a PA. It's only a PA once you start losing more than 40, 50% bone. But you know what? It's actually creating a system with the team. This is the take home. Okay, folks, implant disease happens faster than perio disease. We need to be on it. We can't take this two or three year thing or miss a radiograph on an implant. We've got to be on it because what you're going to hear me say here in a moment, Phil, is that when you see implantitis, what are you going to do? That is going to be my next question, so you're reading my mind. Before we get to that exactly, the treatment, let me just ask you about the prognosis. If you compared traditional periodontal disease on a lower canine with an implant that's a lower canine, and they're comparable as far as the bone loss, it's already past the gingivitis stage, so now you're into the attachment and you're starting to lose connective tissue and you've actually lost some bone. When you compare those two scenarios, Is the prognosis for the implant much worse than the traditional periodontal disease? We're talking the same. That's a great example. In fact, I'm going to use that in the future. I'm going to steal it from you. Let's talk about the surface. On a canine, you've got a smooth surface, but still cementum to a certain degree with Sharpies fibers, attachment, and PDL. On the implant, you have a porous surface now. You had a machine surface at the top. which we wanted to get some type of, you know, hemidesmosal connection. But once you get back into no person's land, you get into porosity, which is the worst thing you could have even on a restored material, right? That's the first thing. You know, it's the devil in the deep blue sea. You know, one year, we want all implants to be machined, but they would not deintegrate. Then next year, we want everything to be porous, which means if you lose any attachment... then you're dead because it's going to be a haven for the microflora. The second one is equally. Do you know what threads are on an implant? It is furcations on steroids. Here we are worried about a class II furca on a mandibular molar, one little class II furca. Do you know what it is like once you get into the threads? You've got a circumferential furca. And if you've got three threads, you've got three circumferential fircus. And the issue is, is how do you get into those fircus to decontaminate if you're going to have any kind of repair? That, between porosity and the anatomy of the implant, we are incredibly vulnerable. So the challenge, obviously, is there for the GP that sees this. Are they going to refer that to a periodontist almost routinely if they start to see implantitis? Unfortunately, I would suggest to you that we have some great general practitioners like we do with all our specialties. But we get into this mentality of monitor. Now, I'm not going to suggest you can monitor periodontal disease because I have to be careful with that. But I do want to reinforce going back to your two canines. Please, my friends, do not monitor implantitis. What we are recommending now. is the first time you see implantitis, you need to flap it, you need to degranulate it, you need to decorticate it, and you need to decontaminate it. Now, we love using lasers for that, but it does not necessarily sense that somebody says, Sam, I don't have a laser. Okay, fine, but it doesn't mean you should still not reflect a flap, decorticate, degranulate, and decontaminate, even if you have to take a piece of cotton and put it in chlorhexidine and scrub the surface. Or, one of my favorites, is to use the new airflow devices with erythritol or glycine. Which, by the way, we're now demonstrating that for the dental hygienist, this is becoming the most important device in maintaining implants, is the utilization of these air medicament airflow devices that are sort of an offshoot of a... a power, but not the ProphyJet, but they have erythritol or glycine in them. These things are phenomenal. Do you have any that you could recommend? Well, the one that I think has probably a significant amount of science and has a track record is going to be EMS. It's going to be the master prophylaxis unit from EMS. We try to move more towards the units that are console-based. Because the handles themselves are much more lightweight, and the powder comes through the bottles that are with the console, rather than having to have the powder themselves in the handheld devices. You know, before I forget it, Phil, we might also want to talk about the patient. Can we talk about that for a moment? Yeah, I was going to actually ask you, what are some of the preferred methods that the hygienist and the dentist should be presenting to the patient? as far as managing early implant disease. I guess if it's severe, I don't know how much they could do at home, but you tell us. Well, it is. The mucositis is the target. And after you've managed the implantitis, then it's the target. However, we do know this. The devices that you use for natural teeth and restored teeth are not the devices necessarily that you're going to use around implants because, first of all, the anatomy is different. I mean, you've got what I call a mushroom. You've got a stalk with this incredible convex device around there. And how do you get there? How does that patient get there? Well, here's what we found. Floss is probably not indicated with implant disease. Unfortunately, certain studies have demonstrated that when one uses floss and there's anything sharp around the area, it creates something called the floss nest. and that is remnants of the floss stick around the plant and they accumulate over time and when they accumulate over time it's a great nidus for the microflora so if i'm not going to use floss i mean floss of any kind what am i going to use and that is where we go into the mainstays something like a soft pick especially the advanced model soft pick things like interdental brushes The bigger you can get, the better you are. And we're, and actually, we actually dip it in medicaments. We don't have any kind of particular brand name, but anything that has menthol, thymol in it, we enjoy. But the other thing is this increased numbers of all-on-six, all-on-fours, where patients can't remove them. There, the only way I do know is interdental brushes. and into brushes. There is no other way. A patient is not going to thread through those things. These tools are important because they maintain their integrity versus floss, which, as you said, it sticks to the implant and then it forms this matrix where it's ideal for biofilm to colonize. So you're saying that the integrity of these tools, they don't break down. They're residual coming off these tools from Sunstar. At least I know for interdental brushes with Sunstar, all of those wires are coated. So you get no galvanic. You can't get any damage to the implant surface at all. They're polymer or they're coated. And they come in so many different sizes. And we always say, use the largest the patient can get through there. And they also hold medicaments well. In my mind, we should be giving these things out like candy in every single implant patient, whether it be mucositis, implantitis. They should be using these things religiously. And, you know, we don't even say you have to go from the lingual or the palatal. If you can just go from the buccal, because all of this is about one thing, disrupt the biofilm. Right. Now, why would the patient have to wait till they got mucositis? Why couldn't they use these brushes after the implant's fully healed as a preventative thing? Every dental practice should have a protocol that every single implant, from preventive to therapeutic, should be using these devices. Okay. Because you mentioned the target is mucositis or peri-umplantitis that's healed, and now it's at a better level. I'm just thinking preventatively, why not just have these patients when they visit the hygiene department say, hey, here's a handful of these things, go out and get them. Can you buy these things at Walmart and retail? They are absolutely everywhere. Okay. So they don't have to get them from the dental office? As you and I both know, just make sure you get quality and not the knockoffs. and the quality is there and you know the good thing about it is that these companies like sunstar their their education for dental professionals is at such a high level that most folks are aware of that but i do want to go back every single study we've ever had on risk factors for mucositis is related to the biofilm so if you never let it happen It won't happen unless the implant was just placed, unfortunately, poorly or what have you. You know, all implants are not lost just because of biofilm, but most implants are. So if a patient uses floss generally, and you're a periodontist, and I'm just asking you this from your expertise, and they have implants, I guess you're saying they have to stop using the floss for those particular teeth and then reach for the brushes, the interproximal brushes. I mean, or do you suggest something else? Well, this is going to hit a nerve with some of our listeners. Well, we like to do that on this podcast, so no problem, Dr. Lau. Here we go. I can see the value of floss in dentistry. I never have. You do not see the value of it? No study has ever shown it. You know, the reason no one ever said it is because it sounds like sacrilege. It's blasphemy. However, you and I both know that the oral health profession should be based on science. And the fact is, it really wouldn't matter because most studies show only 7% of patients floss every day anyway that are actually patients of record. So the bottom line is, why wouldn't one use something that you know they're going to use that the studies show is as effective as floss, but you get a higher compliance? Why wouldn't you want to do that? And that's also, Phil, why you know that we're seeing what? More and more attention to... this whole game of water flossers you know right now the the hype is is actually interproximal bio you know with water flossers now we have to go back because we periodontists believe that things are mechanical that water flossers are beautifully adjunctive but you've got to have mechanical so we say use your interdental brush use your soft pick And also then follow it with your water flosser as an addition. And you know what? You've heard this. People will say, well, you know, ever since we put them on these water irrigation devices, we're seeing improvement. No, what you're seeing improvement in, superficial inflammation. Oh, superficial inflammation. Yeah. Yeah. Don't be, you know, don't be mesmerized by the lack of superficial inflammation. We're secular diagnosticians. That's the difference. Right. And I hear you. And I do hear some experts in the field of periodontology talking about this more. But from my own experience, I've been flossing. I'm one of those 7%, but I'm also a dentist, retired. I've been flossing every day, once a day, for probably 35 years. I don't think I've missed a day in 35 years. And I went to the dentist about four months ago, and they took some bite wings. The dentist says, you know, your bone level is literally of a 16 year old. So it's worked for me. But what I think the problem is with floss is that I don't think patients are using the floss efficiently or as well as they should for whatever reason. They just don't feel comfortable manipulating the floss to where they can get and achieve that mechanical debridement of the biofilm that they should be getting. Whereas maybe I'm a dentist and I have the... ability to do this a little bit better because I know to lean the floss against the tooth and avoid manipulating the gingiva, the free gingiva, as much as I can. I don't know what the reason is, but it seems to me it's worked. And I remember in dental school, when I first went to dental school in my first year, Jay Siebert, I don't know if you remember that name, Dr. Siebert. Oh, very well. Very well. Yeah. So he was a very good friend of mine. He died an untimely death from a rare disease. But the first week of... he passed around a skull to everybody in the class at Penn, University of Pennsylvania Dental School. Everybody got to see the skull. We looked at it. We brought the skull back up to him. And he said, this patient died at 95 years old. And she allowed me to use her skull for teaching purposes. Because when you looked at her dentition, she had almost all of her teeth and her bone level was literally unscathed. I don't know how many 20-year-old people have had bone level like that. And he basically said she flossed her whole life. So that's why I'm still a believer of floss, looking at the other side. But I understand your point, Dr. Lau, about scientific data. I will tell you the contribution that that patient she gave to Jay Sieber is phenomenal, including the histology. You probably are aware the histology that was done and her literally getting, you know, she was so indebted to him. that she gave literally her head to him to demonstrate, and you're right, the bone levels, and he was demonstrating. that if they maintain themselves and you maintain them at the chair, we would probably eradicate most periodontal disease that's out there. But it still comes down to, unfortunately, the elephant in the room called compliance. You know, it just comes down to compliance. And glossing is just that to a certain degree for the average patient, it's just an extremely complex requiring dexterity. As a grooming aid, I mean, you know, brushing your hair, washing your face, but taking 28 little ivory objects and trying to pop a piece of string through there. Some people can get it and some people don't. I'm just suggesting that for our population, if they do it, great. But if they don't, here are the alternatives. Right. And most people are not doing it. efficiently and effectively and based on that if there was a really long-term scientific study i think there was obviously some studies that show that flossing does not remove biofilm that effectively in many areas of the mouth much of the biofilm is still there after people floss only in the areas of concavities it does show and you know how we do what we call it squeaky clean that's what i always did do it till it squeaks do it till it squeaks Because they need an end point. If there's no end point, how do they know they go to the next tooth? That's what we always, that's what my team on, do it till it squeaks. But the problem is, even when it squeaks, it doesn't get into the concavities. It doesn't get into the furcus. And unfortunately, we know the number one tooth lost in this country is a percated mold. Well, listen, we've learned a lot here, Dr. Low, covered a lot of stuff, and there's more to cover on future podcasts. And I really respect your time and thank you very much for joining us. And we look forward to your next one. And we really look forward to having you do more webinars for Viva Learning as well. You've done a fantastic job in the past. Thank you so much. Well, thank you, Bill. And keep those plus companies happy. Okay. Well, thank you.