Naval Postgraduate Dental School Navy Medicine Professional Development Center 8955 Wood Road Clinical Update Bethesda, Maryland 20889-5628

Vol 40. No. 2 July 2018

Periodontal Probing Around Dental Implants Lieutenant Brooke Ahlstrom DC, USN, Commander Yasir Bahrani DC, USN

Background the most reliable prognostic indicator of disease progression Peri-implant diseases are classified into two categories: Peri- followed by MR and BoP. Finally, Froum and colleagues noted implant mucositis, which is defined as inflammation confined to that probing around an implant, as in natural dentition, is useful to the surrounding peri-implant soft tissue, and peri-implantitis, detect the presence of disease on the buccal and lingual aspect of which extends to the supporting alveolar bone around an implant. implants that would be otherwise difficult to discern on a standard Initial estimates from The Consensus Report of the Sixth European radiograph4. Workshop on determined that peri-implant mucositis was found in as high as 80% of implant patients (50 % Risks for Probing Around Dental Implants of sites) and peri-implantitis was found in 28-56 % of implant There are several concerns that have been cited with probing patients (12-40 % of sites) 1. More recently, a systematic review around implants which have resulted in the misconception that estimated that the mean prevalence of peri-implant mucositis and probing should be omitted or perhaps should only be completed peri-implantitis is 43% and 22% of sites respectively2. With over with a plastic probe. Those concerns include the risk of peri- 3 million people in the US already having an implant placed and implant tissue damage, damage to the implant surface by the the number growing by over 500,000 people annually, peri-implant metallic probe, and risk of bacterial inoculation4. There are some disease will present a significant challenge that clinicians should be important differences between the soft tissues surrounding natural prepared to diagnose and treat3. There is a common misconception teeth and dental implants11. The soft tissue surrounding an implant that probing around dental implants may be detrimental to the may or may not have keratinized epithelium similar to natural teeth; implant abutment or the fixture itself and is therefore routinely however, implants lack gingival, transeptal, and periodontal omitted from dental examinations4. The purpose of this update is ligament fibers that provide anchoring support. The lack of these to discuss the rationale and the suggested risks associated with fibers presents concerns for potential damage to the peri-implant probing around dental implants, explain the differences in probing soft tissue while probing. However, Etter et al. evaluated the soft- healthy versus diseased peri-implant tissue, and provide basic tissue healing in dogs following a standardized probing force of recommendations for probing peri-implant tissue. 0.25N and found that, although probing resulted in a separation of the from the implant surface, epithelial re- Rational for Probing Around Dental Implants adaptation occurred within five days12. The authors concluded that Reports in the literature have discussed difficulties with accurate probing dental implants does not seem to significantly alter the probing around natural teeth to include tooth malposition, peri-implant tissue. With respect to surface damage by the probe, inflammation of the soft tissue, , differences in probe it has been hypothesized that probing a or abutment diameters, and probing force5,6,7. Although the tissue surrounding surface, especially with a metal probe, can roughen the surface natural teeth and implants differs in terms of composition, these which can increase bacterial accumulation and cause an infection same factors can also impact probing around the peri-implant or even lead to implant failure13. However, in an in vitro study tissues. Similar to probing around teeth, consistency in evaluating surface effects of plastic and metal periodontal probes reproducibility in probing can be achieved with dental implants. on machined titanium abutments, researchers found increased Christensen et al. found that using three different devices that surface roughness and residues after probing with a plastic probe probing around implants has adequate reproducibility with a 0.25 when compared against a metal probe 14. The authors noted that N force, which is considered a light probing force8. Even with this the rounded point of a metal periodontal probe burnished the light force, providers should be aware that pain or discomfort grooves on the implant-machined abutment, while the plastic probe during peri-implant probing may be experienced by the patient. In left a significant amount of attached plastic particles and debris on a recently published study, Stanner et al. found that a standard the surface of the same abutment. It was also emphasized in the probing force of 0.23 N caused significantly more pain and study that to date, there are no reports linking either development discomfort around dental implants compared to natural dentition9. of peri-implantitis or implant failure to these surface alterations Similar to diagnosing , peri-implant diseases are produced by plastic probes. Regarding possible bacterial diagnosed through collection of the following parameters: Bleeding inoculation from using the periodontal probe between multiple on probing (BoP), suppuration, probing depth (PD), radiographic sites, Greenstein and Lamster found the transfer of microorganisms bone loss, and implant mobility, with three out of the five from periodontal probing does not result in colonization of bacteria parameters requiring the use of a periodontal probe for assessment. or lead to an infection of the site. They concluded that the concerns These factors are significant as they provide the clinician with of spreading bacteria and initiating periodontal disease or infection possible predictors of development of peri-implantitis. In are unwarranted15. Providers must keep in mind that this study evaluating PD, mucosal recession (MR), and BoP, Monje10 found looked at the transfer and colonization of bacteria around teeth and that sites exhibiting PD ≥ 4.5 mm, BoP, and MR were significantly there has been no study to date that has evaluated the possible more likely to be diagnosed with peri-implantitis, with PD being impact of inoculation of those bacteria around dental implants.

Probing Around an Implant in Health versus Disease http://www.aaid.com/about/press_room/dental_implants_faq.html. It has been established histologically that depth of probe Accessed April 2, 2018. penetration is greater in diseased versus healthy sites in the natural 4. Froum SJ, Wang WCW. Risks and benefits of probing around dentition by over 1mm5. Lang et al. using a dog model, found natural teeth and dental implants. Compend Contin Educ Dent 2018; similar results around implants, with the depth of probe penetration 39: 20-25. being directly proportional to the degree of inflammation16. 5. Fowler C, Garrett S, Crigger M, Egelberg J. Histologic probe Additionally, in the experimentally induced peri-implantitis sites, position in treated and untreated human periodontal tissue. J Clin they noted that the probe tip penetrated past the connective tissue Perio 1982; 9: 373-385. attachment by a mean of approximately 0.5 mm when probing 6. Lang NP, Nyman S, Senn C, Joss A. as it around an inflamed implant site. In another comparison study relates to probing pressure and gingival health. J Clin Perio 1991; evaluating probe penetration in healthy and diseased sites in both 18: 257-261. natural teeth and implants, Shou17 et al. found that both slight and 7. Van der Zee E, Davies EH, Newman HN. Marking width, severe marginal inflammation surrounding implants were calibration from tip and tine diameter of periodontal probes. J Clin associated with probe penetration closer to the bone than was seen Perio 1991; 18: 516-520. 8. Christensen MM, Joss A, Lang NP. Reproducibility of automated in teeth. With the results of these studies in mind, it is vital for the periodontal probing around teeth and osseointegrated oral implants. clinician to evaluate the integrity of the surrounding soft tissue Clin Oral Impl Res 1997; 8: 455-464. around implants and consider how probing depths may be affected 9. Stanner J, Klum M, Parvini P, Zuhr O, Nickles K, Eikholz P. by the inflammatory conditions of the peri-implant tissue. Discomfort/pain due to periodontal and peri-implant probing: implant type and age. J Clin Perio 2017; 44: 749-755. Basic Recommendations for Probing Around Dental Implants 10. Monje A, Cabello-Serrano J, Nart J, Penarrocha D, Wang, H, Rakic When assessing the health of dental implants based on Froum et M. Diagnostic accuracy of clinical parameters to monitor peri- 4 al. the following protocol is recommended : implant conditions: A matched case-control study. J Perio 2018; 89: (1) Use a smooth un-indented probe with a round tip 407-417. diameter of approximately 0.4mm to 0.5mm. Since 11. Berglund T, Lindhe J, Ericsson L, Marinello CP, Liljenberg B, probing does not necessitate the use of a plastic probe, a Thomsen P. The soft tissue barrier at implants and teeth. Clin Oral UNC-15 or WHO (PSR) metal probe can be used. Impl Res 1991; 2: 81-90. (2) Use a gentle probing force of ≤0.25 N 12. Etter TH, Hakanson I, Lang NK, Trejo PM, Caffesse RG. Healing (3) Clean the probe in after it is used around after standardized clinical probing of the peri-implant soft tissue infected sites such as periodontal abscesses or sites with seal: a histomorphometric study in dogs. Clin Oral Impl Res 2002; suppuration before using the instrument to probe other sites 13: 571-580. (4) Finally, in cases that are difficult to access with a probe 13. Speelman JA, Collaert B, Klinge B. Evaluation of different methods such as splinted, or hybrid-designed restorations, remove the to clean titanium abutments. A scanning electron microscopic restorative structure before probing if possible. study. Clin Oral Implants Res. 1992; 3(3): 120-127. 14. Fakhravar B, Khocht A, Jefferies S, Suzuki JB. Probing and scaling

instrumentation on implant abutment surfaces: an in vitro study. Conclusion Implant Dent 2012; 21: 311-316. As implants are commonly being used to replace missing teeth, the 15. Greenstein G, Lamster I. Bacterial transmission in periodontal value of appropriately examining peri-implant tissues clinically disease: a critical review. J Periodontol. 1997; 68(5): 421-431. cannot be underestimated. Similar to the benefit of probing around 16. Lang NP, Wetzel AC, Stich H, Caffesse RG. Histologic probe natural teeth, probing around dental implants is the most effective penetration in healthy and inflamed peri-implant tissues. Clin Oral non-invasive technique for assessing peri-implant tissue health. Impl Res 1994; 5: 191-201. Probing peri-implant tissue does not necessitate the use of a plastic 17. Shou S, Holmstrup H, Stoltze K, Hjorting-Hansen E, Fiehn NE, probe as has been previously thought. While some studies have Skovgaard LT. Probing around implants and teeth with healthy or discussed peri-implant tissue damage and implant/abutment inflamed peri-implant mucosa/gingiva. Clin Oral Impl Res 2002; 13: surface alterations from probing, the tissue damage is reversible 113-126. and the risk of those surface changes having an undesirable clinical outcome on the dental implant has not been noted in the literature. Lieutenant Ahlstrom is recent graduate from the NPDS Periodontics Department. Commander Bahrani is a faculty member of the Periodontics Department. References 1. Lindhe J, Mehle J Peri-implant diseases: consensus report of the The opinions and assertions contained in this article are the private ones sixth European workshop on periodontology, J Clin Perio 2008; 35 of the authors and are not to be construed as official or reflecting the (8 Suppl): 282-5. views of the Department of the Navy. 2. Derks J, Tomasi C. Peri-implant health and disease. A systematic The Naval Postgraduate Dental School is affiliated with the Uniformed review of current epidemiology. J Clin Perio 2015; 42: S158-S171. Services University of the Health Sciences’ Postgraduate Dental College. 3. Dental Implants Facts and Figures. American Academy of Implant

Dentistry website.