The dental team routinely uses all of these modes of clinical assessment, except for periodontal probing around peri- implant tissues that appear to be in a state of good health. To properly assess peri-implant status longitudinally, the team should record the baseline data and data from subsequent recall visits in the daily progress notes. After a thorough intraoral examination, unless there is visual evidence of soft tissue changes (i.e., inflammation of peri- implant tissue with even slight attachment loss or mucositis), routine probing of the peri-implant tissue should not be performed. The dental team should inform the implant patient that current evidence indicates lifelong maintenance is required for dental implants and implant-supported restorations (Pirc and Dragan, 2017). The dental care professional should be cognizant of each patient’s level of home care effectiveness and the systemic Case scenario: The reluctant maintenance patient Bob is a 50-year-old man who informs his hometown dentist that he is interested in getting dental implants. Bob states that he has been waiting his entire adult life for this moment and finally has the funds for the treatment. He has seen the ads on television and is looking forward to “teeth in a day.” In addition, Bob states that he has always been afraid of the dentist and is looking forward to never having to see one again. The patient explains that if he does not have teeth, then he has no reason to go to the dentist. The patient then offers to write the dentist a check for the entire cost of the treatment and asks when he can begin the process. Question: Should Bob’s dentist proceed with care for this patient at this time? Unfortunately, Bob’s sentiment is echoed by many dental patients. Bob is presenting to his dentist’s office with unrealistic expectations, and it is the responsibility of the dental provider to explain the realities of dental implant therapy to him. Moreover, Bob’s current financial freedom should not change how the dentist responds to his request. It is the dentist’s responsibility to act ethically and responsibly. First, restorations supported by dental implants require maintenance by both the patient and the provider. If the patient is not committed to home hygiene, he or she should carefully reconsider the option of implant-supported restorations. Additionally, the dental professional must perform recall for both patient hygiene and evaluation of the implant restorations. Often, the dental implant restoration may have a mechanical
health and periodontal status of the peri-implant tissues when determining the frequency of these recare intervals. With dental implant patients, the dental professional must also examine the prosthetic components for plaque and calculus and evaluate the stability of the implant abutment. He or she should take radiographs of the dental implants periodically during maintenance recall as indicated and appropriate. For screw-retained dental implant restorations, the dental professional may remove the prosthesis periodically to assess the status of the peri-implant’s hard and soft tissues, the acceptable mobility of the prosthetic components or the implant fixture, and the patient’s level of home care effectiveness. The dental professional should assess and diagnose as appropriate any symptoms of infection, radiographic evidence of peri-implant bone loss, and/or neuropathies. or biological complication that the patient cannot identify. With regular recall and maintenance appointments, the dental professional can identify and fix these complications. In addition, complications are often easier and less expensive to fix when they are identified early. When patients are aware of these facts, they may be more motivated to return for regular follow-up. The patient must also understand that there are costs for maintaining dental implant restorations, and he or she must be able to meet these financial obligations in the future. This is critical for the patient who states that he has been saving his money for this one treatment and may not have the funds for future care. It would be irresponsible to perform a treatment that has expensive follow-up or repair requirements because these costs would be the responsibility of the patient in the future. Once the patient has a better understanding of the current and future fees associated with treatment, the desired treatment plan may change. Finally, the dental professional should counsel the patient regarding a realistic timeline for treatment; the patient should not expect to have everything completed in one appointment if this is not clinically possible. Patients also obtain information about care from various sources, including friends, family, television, and the internet, and this information may not be correct. In such cases, it is the role of the dental provider to clarify and correct misinformation so the patient can make an informed choice about current or ongoing treatment.
IMPLANTS VERSUS NATURAL TEETH
It is essential to understand the periodontal relationship between the gingiva and the structure it attaches to, regardless of whether it is a natural tooth or an implant. The gingival cuff is composed of two zones around both natural teeth and dental implants. The crestal connection with the tooth or implant is the junctional epithelium, which acts as a physical barrier to the ingress of bacteria, limiting or preventing inflammation. The difference between natural teeth and implants is the strength of the connection between the junctional epithelium and the structure it attaches to. Below this circumferential zone lie the connective tissue fibers. The fiber orientation of the gingival cuff around a natural tooth attaches perpendicular to the long axis of the tooth. These oriented fibers act as a barrier when a periodontal probe is inserted within the sulcus, in that the probe tip advances apically until the tip contacts the perpendicular fibers and is halted. The gingival cuff around an implant does not sow this orientation. With an implant, the gingival fiber orientation is parallel to the implant’s long axis. When the dental provider inserts a periodontal probe into the sulcus around an implant, the advancing probe tip passes between the fibers of the
gingival cuff until the crestal bone prevents it from further advancement. The peri-implant mucosal seal surrounding an implant may be a less effective barrier to bacterial plaque than the periodontium around a natural tooth. The keratinized tissue around an implant has a decreased vascularity and lacks a true connective tissue attachment compared to that of a natural tooth which makes the implant more vulnerable to bacterial ingress (Fody and Marsh, 2020). Furthermore, there is less vasculature in the gingival tissue surrounding dental implants than in the tissue around natural teeth. This reduced vascularity along with the parallel-oriented collagen fibers adjacent to the body of any dental implant make them more vulnerable to bacterial insult (Atout, et al., 2018). For these reasons, during recare appointments, peri-implant periodontal probing is advised only where there are signs of infection (i.e., exudate, swelling, bleeding on probing, inflamed peri-implant soft tissue) and/ or radiographic evidence shows peri-implant alveolar bone loss. In addition, dental providers should not perform routine periodontal probing of dental implants because this procedure could damage the weak epithelial attachment around them,
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