Dr Aly Virani is the Clinical Director for North Cardiff Dental & Implants. He's worked with the Association of Dental Implantology (ADI) and International Team for Implantology. Aly also teaches surgical techniques and treatment planning through Practical Implantology and on his website, Transformative Education in Dentistry (TED).

Dr Aly Virani often gets referrals from general dentists who aren't sure how best to manage implant disease. He broke down how the management of periodontal and peri-implant diseases differs and busted some implant myths.

You can rewatch the webinar, hosted by Dental Update Webinars, below. Or, keep reading to learn more about managing and monitoring patients with implants!

Implant-related diseases

Let’s start with the basics. Gum disease related to dental implants is peri-implant disease, or peri-implantitis. It's related to poor oral hygiene like normal gum disease, gingivitis and periodontitis. But the progression and onset of peri-implant diseases is far faster than periodontal diseases.

In the same way that untreated gingivitis leads to more serious periodontitis, peri-implant diseases can also progress. Peri-implant mucositis is an inflammatory condition affecting the soft tissues surrounding an implant. It is reversible and treatable with non-surgical methods.

Peri-implantitis is irreversible. It leads to the loss of bone that supports an implant, and affects the attachment of the implant. More invasive intervention is often needed for successful outcomes.

Peri-implant diseases are common - with around half of patients likely to get some kind of disease. The rates of perio-implantitis are about 20%, but Dr Virani thinks this is underreported.

Risk factors for peri-implant diseases

There are several risk factors associated with peri-implant diseases:

• Poor oral health
• History of periodontal disease
• Smoking
• Infrequent recalls
• Diabetes
• Alcohol
• Genetics
• Improper restoration design

The problem with implants is the anatomical changes that have taken place. Implants have fewer surrounding cells and connective tissues.

This means the disease progresses quickly. Dental professionals have to act faster than they would with patients without implants.

Dentists must work with patients to minimise the disease's effects,  protecting the long-term health of the peri-implant tissue. That's why it's important for you to understand the differences between these conditions and how best to treat them.

Diagnosing peri-implant diseases

Making an accurate diagnosis is essential when deciding on a treatment pathway. When it comes to peri-implant diseases, speed can also be crucial.

A peri-implant disease diagnosis is often the result of identifying inflammation in the soft tissues that surround the implant. Signs to look for include:

• Any mobility caused by loss of soft tissue support and bone loss
• Bleeding on probing in the pockets surrounding the restoration

Sometimes, bleeding on probing is the only indication of disease.

If you suspect peri-implantitis, you need to carry out a radiograph to assess the level of bone loss. It’s essential for producing an accurate diagnosis. CBCT (cone-beam computed tomography) scans are ideal for monitoring bone levels. They should be carried out as soon as possible, but these will be done in the specialist setting if required.

What to record during appointments

According to Aly, there are essential and optional things to note in the patient's record about their implant health.

With bleeding on probing being the only reliable disease indicator, recording this this is essential. Document the position of implant(s) and mobility, pain, suppuration, swelling or exposed threads as proof of a clinical exam.

If you do notice bleeding, state what happened next. Document that you offered a referral to a specialist (even if declined), or that you made one with consent from the patient. Note that disease progression is a possible consequence of declining a referral.

Optional things to document include: radiographs, plaque and 6-point pocket chart scores. You should also consider documenting any changes to scores.

Knowing when to treat and when to refer

According to Dr Virani, he'd accept a referral without this 'optional' information. That's because he will always investigate further when general dentists note bleeding.

Dentists that are confident diagnosing and treating can do so.

For unsure general dentists, recognising and recording a non-health state is most important. If this is you, document clinically significant factors and refer on to a specialist.

Interventions: non-surgical and surgical

You need a combination of non-surgical and surgical interventions to treat peri-implantitis. Non-surgical treatment alone will only help to slow down the progression. It won’t limit the risk of implant and bone loss.

You must help patients improve their oral health and minimise any risk factors.

Debridement and improved oral health

Non-surgical treatment means mechanical debridement and improved oral hygiene (to reduce bleeding on probing). This will treat peri-implant mucositis, but is not enough to treat peri-implantitis.

Thorough cleaning is essential. You'll need to remove contamination from the surface of the implant and restoration. Surgical resection may be necessary to ensure complete debridement of the implant.

You should consider the effects that the restoration can have on the health of soft tissues. Oral hygiene advice is essential, but it must be specific to the patient and take into account their restoration type.

Other non-surgical interventions include modifying their  restoration to provide more room for cleaning. You should show patients how to clean around their restoration. Show them how to disrupt the biofilm, this will help to minimise the progression of their disease.

Surgical treatment options

The aim of surgical treatment is to get access to clean the restoration - both for the dentist as well as the patient. Be mindful of leaving cement under the gums of someone who is perio-susceptible. These patients will experience bone loss, compared to an 80% chance if you're not susceptible.

Most non-susceptible patients (75%) will recover fully - but only half of the susceptible ones will recover. Success rates for any resective or regenerative procedures will also be influenced by the strength of their oral health. With plaque scores below 10%, there's a 94% survival rate for implants and a 75% chance of the implant being stable.

The importance of regular monitoring for all patients

For effective monitoring and prevention of peri-implantitis, frequent recalls are essential. Patients should visit the dentist every 3 months. But even with two visits a year, they reduce their chance of developing peri-implant disease by 60%.

This is because regular monitoring and cleaning reduces the chance of disease developing. During these follow-up appointments, check the patient’s plaque score. Aim to keep plaque levels below 25% to minimise the risk of diseases developing.

Dr Virani recommends regular maintenance appointments over the long-term. Patients tend to become less compliant three years post-implant. Regular monitoring and excellent hygiene need to continue beyond this to avoid developing peri-implantitis .

Keeping thorough records of activity

As their treating dentist, you also need to keep making thorough records of their progress. This is the only way to monitor their implants and their risk of developing peri-implantitis. Considering that 34% of payouts relate to implants, you want to make sure that you protect yourself from future litigation!

As part of the webinar, Dr Virani shared some of his workflows and explained how he uses technology to help him and his team better manage patients.

Aly uses Kiroku, a digital note-taking platform designed to make completing records easy. He has designed custom templates for monitoring his dental implant patients. This ensures he collects all the relevant information he needs.

Why Aly Virani uses Kiroku

Aly has been using Kiroku since May 2021. His templates help him provide better patient care and he says it has changed his clinical life. "Some people think of note-taking as a tick-box exercise. It can be so much more than that. It can act as a prompt."

By keeping a clear and accurate record of each appointment, he can  easily track changes in his patient’s soft tissue.

He also has a comprehensive record of any oral hygiene and smoking cessation advice he has given. Plus, his notes mean he has a record of bleeding on probing and pocket depth to refer to and compare over time.

He said, "With Kiroku if I'm with a patient and I haven't read something out, my nurse can read out the prompts thatKiroku triggers. For example, we have built in a prompt to check if probing pocket depths have changed. It guides us through our workflows but in a note format."

Dr Virani recommends other dentists use Kiroku for their note-taking too. It allows dentists to record the essential markers for decision-making while treating patients. This makes it easier to recognise when the time has come for intervention and/or referral.

Kiroku users can also take advantage of Aly Virani’s template! It's available to download from our library of over 40 stock templates.

Try Kiroku for free to explore our range of dental implant template from renowned specialists such as Dr Aly Virani and Dr Martin Wanendeya.

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