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Implants · patient case with 5 questions

Implant Maintenance Problems

demo: 57-year-old female

chief: “The gums around my implants bleed and food gets stuck underneath.”

history: Edentulous maxilla restored with an implant-supported fixed prosthesis 3 years ago. Former smoker.

meds: None

findings: Bleeding on probing and erythema of the peri-implant mucosa at three sites. Radiographs show no bone loss beyond the initial remodeling. The intaglio of the prosthesis is concave, with food packing at the tissue interface.

Question 1

What is the diagnosis?

  1. Peri-implant hyperplasia
  2. Peri-implant mucositis
  3. Peri-implantitis
  4. Failing osseointegration
Show answer and explanation

Correct answer: B. Peri-implant mucositis

  • A. Hyperplasia would present as tissue overgrowth rather than the erythema and bleeding described.
  • B. Correct. Inflammation of the peri-implant soft tissue with bleeding on probing but without progressive bone loss defines peri-implant mucositis — the reversible precursor to peri-implantitis.
  • C. Peri-implantitis requires radiographic bone loss beyond the initial remodeling, which is absent here.
  • D. Failing osseointegration presents with mobility and a peri-implant radiolucency, neither of which is described.

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Question 2

What is the first step in managing this patient's peri-implant inflammation?

  1. Mechanical debridement with irrigation using chlorhexidine
  2. Systemic metronidazole for 10 days
  3. Surgical flap access with implantoplasty
  4. Explantation of the affected implants
Show answer and explanation

Correct answer: A. Mechanical debridement with irrigation using chlorhexidine

  • A. Correct. Peri-implant mucositis is reversible. Non-surgical debridement with chlorhexidine irrigation plus reinforcement of home care is the appropriate first intervention.
  • B. Systemic antibiotics are an adjunct at most; they do not remove the biofilm.
  • C. Surgical intervention is escalated to only when bone loss has occurred and non-surgical measures fail.
  • D. Explantation for a reversible soft tissue condition would be indefensible.

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Question 3

How should the prosthesis design be modified to prevent recurrence?

  1. Make the intaglio surface more concave to create a cleansing reservoir
  2. Reshape the intaglio surface to be more convex, eliminating areas where debris collects
  3. Add interproximal contact tightness to block food entry
  4. Extend the flanges further onto the mucosa
Show answer and explanation

Correct answer: B. Reshape the intaglio surface to be more convex, eliminating areas where debris collects

  • A. Concavity is precisely the problem here — it creates an uncleansable trap.
  • B. Correct. A convex tissue surface bulges gently outward, allowing floss, brushes, and irrigation to sweep the interface. Concavities and ridge-lap contours trap plaque and debris.
  • C. Tightening contacts does not address the tissue-surface contour where the debris is accumulating.
  • D. Extending flanges increases the covered area and worsens hygiene access.

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Question 4

Which hygiene instruction is NOT appropriate for this fully edentulous, implant-restored patient?

  1. Daily fluoride mouth rinses
  2. Interdental brushes sized to the embrasures
  3. A water irrigator directed at the tissue interface
  4. Superfloss or floss threaders under the prosthesis
Show answer and explanation

Correct answer: A. Daily fluoride mouth rinses

  • A. Correct — this is the exception. Fluoride prevents caries in natural tooth structure. In a fully edentulous patient with titanium implants there is no enamel or dentin to protect, so fluoride rinses serve no purpose.
  • B. Interdental brushes are a mainstay of peri-implant hygiene.
  • C. Water irrigation is effective at the tissue-prosthesis interface where brushes cannot reach.
  • D. Floss threaders and superfloss are standard for cleaning beneath a fixed implant prosthesis.

Note: There is a further nuance: high-concentration acidulated fluoride can corrode titanium surfaces, giving a second reason to avoid it around implants.

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Question 5

On the day of implant placement, what must be achieved for osseointegration to proceed?

  1. Complete radiographic bone fill
  2. Primary stability
  3. Immediate functional loading
  4. A keratinized tissue band of at least 4 mm
Show answer and explanation

Correct answer: B. Primary stability

  • A. Radiographic fill is an outcome of healing over months, not a day-of-surgery requirement.
  • B. Correct. Primary (mechanical) stability at placement prevents micromotion during healing; excessive micromotion produces fibrous encapsulation instead of bone apposition.
  • C. Immediate loading is an option in selected cases, never a requirement, and depends on having achieved primary stability first.
  • D. Keratinized tissue aids long-term maintenance but is not the determinant of osseointegration.

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