Can I Probe This Implant? – GF013

Jaz’ Introduction:
Hello, Protruserati. I’m Jaz Gulati and welcome to this group function. Now if you’re new to the podcast, welcome, great to have you. A group function is where we work together as a team to find out a solution to a common problem. And the problem I’m presenting today and I’m hoping to get a good answer from Pav today is ‘Can you probe around implants?’ And what I mean by that is, I was fed a lie or a semi lie at dental school, like someone told me, I don’t know who it was. But if you use a metal probe, to do a periodontal probing chart of an implant, you will scratch that implant and therefore that will harbor bacteria. And therefore you should not be probing around implants. So for the longest time, I didn’t check the periodontal health of implants and it sounds really bad. But as a GDP who doesn’t place implants, not much to do with implants. I thought that was the right thing to do. I thought I was doing less harm by not inserting my Williams or WHO or CPITN probe in the sulcus to check for the periodontal health because I didn’t want to scratch the implant. I was scared of scratching the implant if you like. So I was expecting this to be a really quick group function. And I thought Pav was saying Yeah, you totally can. It’s all good. But Pav of being Pav, an amazing guy he is. The only does he give us a really good definitive answer at the end, where he talks about the rationale of what the concerns are maybe and how each actually look a little bit deeper than Can you probe? Can you not? Because there’s some anatomical variation, so I’m not going to spoil it for you. Let’s join this group function with Dr. Pav Khaira. That man again. Pav Khaira.

Main Interview:
[Jaz] Dr. Pav Khaira, welcome back to the podcast, my friend. How are you?

[Pav]
I’m very good right now. How you doing?

[Jaz]
Yeah, great. So it is Pav Khaira from The Dental Implant Podcast. And I’m gonna just pick your brains. You need to teach us something today. You need to speak to me like I’m five years old. Because this, the following questions I’m gonna ask you on this group function today is very much basic things that you’re probably gonna laugh at me like Jaz, why you asked me these basic questions? But I’m sure with the referring dentist that you’ve met and your colleagues, like when it comes to implants we come out in dental school, like a lot of other topics. And we’re like, where do we even begin? So just before we dive into that, just reminder on people who perhaps didn’t listen to our episode on finding your niche. I think it was episode 76 from memory. Do listen to finding your niche, it’s a cool one where we discover what is like your calling in dentistry. So do check that one out. But just remind us what is it that you do other than these amazing transformations that you posted on our telegram group.

[Pav]
So thank you very much for having me on Jaz, I’m going to be cheeky and just upload this as the next dental implant podcast episode as well as your record. We have the same video editor. So it’s an easy way. Firstly, I just wanted to say that there’s no such thing as a silly question. This is something that I learned really quite early on, either you know, or you don’t know, it’s really that simple. And I think anybody who doesn’t know who’s asking questions at that point that then they shouldn’t feel embarrassed or anything along those lines. So if I am being overly complicated with my answers, please feel free to remind me because obviously, for me, this is fairly straightforward stuff. And you know, when I get excited about implants, that’s it, mouth starts. Okay? We all know.

[Jaz]
We’re going to start talking about at the cellular level, biological level. No, we’re gonna go way simpler than that today. I know the kind of stuff that you talk about you love that you absolutely love that. And that’s amazing to see though your passion is so..

[Pav]
I’m gonna make it really tangible for you guys as well. So a little bit about me. I graduated in 2002. I did loads of different things. You know, I ended up getting bored quite quickly. It was one point I was doing endo for smile makeovers. And ironically, I just didn’t make surgery. I didn’t make implants. And then I ended up getting into implants. And I was like, Oh, actually, I really love this a lot. I’m now at a position where I am fortunate to be at EVA dental four days a week, and I mentor other dentists and I started working at another practice one day a week as well. And I placed approximately 1800 to 2000 implants a year. So that’s actually quite a big number. And yes, you know, when you when you place big numbers, you learn to prevent a lot of mistakes, but you still see them, you know, anybody turn around and say you have 100% success rate. This is something that I’ve alluded to before, they are either lying or they’re only placing one or two implants per year because if you place one or two implants per year, it’s quite easy to have 100% success rate. So yeah, I mean, that’s just a little bit about myself, I do the surgical aspects of it. I also undertake the restorative, because you can’t separate them. You know, it’s that intrinsically linked together. So that, you know, that’s just a little bit about me.

[Jaz]
Amazing. I mean, it’s crazy. That number you mentioned, you probably do more implants than I do checkups. You probably do more implants than I do composites. You do. You do more implanst than any procedure. That’s pretty spectacular. So you’re totally the right man for this. So question number one of three in this group function is m, can I probe that implant? Now to give you some background behind this question, it’s something that you may have heard before. Now, I don’t know whether it is a myth or not. And I think it is, but let’s just find out the whole thing about if you use a metal like a Hu probe, or a CPITN, a metal probe, or an implant, you will scratch the implant, which will then harbor bacteria, and it’ll be a never ending spiral of peri-implantitis in future. And therefore, dentists all over the world. I’m sure they are. I’m sure they are, are doing their BP and they skip the implant and they carry on. Tell us about this.

[Pav]
So the question that I understand is can you probe around implants?

[Jaz]
Can you probe with a metal probe aroung implant? Or is it a myth that you shouldn’t, you can’t, or just tell us generally about how to check the periodontal health of an implant in a safe way.

[Pav]
Okay. Do you want me to be really unhelpful now? Because you know, what I’m like, it’s one of those. Okay, so the answer to your question is, yes, you can, and no, you can’t at the same time, I’m going to expand on that right now. Okay?

[Jaz]
Sure.

[Pav]
I think we need to take half a step back and understand what’s happening a little bit. Okay. So when you receive the final outcome of or, let’s just say, restored single implant crown, okay? So there’s a number of ways that it can be done. The way to get the best outcome isn’t done very often, because it’s more time consuming, it’s more difficult to do, okay? So the kind of the standard way that most people out there do it, which is kind of accepted is you have quite a narrow implant in relation to your ridge, which is the same height as the alveolar crest. And then radiographically, it looks like a lollipop, tomato on a stick is what it’s called. So you get this sudden, you get this sudden, really, really extreme what we call emergence profile, okay? Now, so probing around implants is different to probing around teeth, okay? Because when you’re probing around teeth, you’re immediately going into the periodontal ligament. If you imagine you’ve got this really wide implant, sorry, really narrow implant, or really wide crown. If you’re probing straight down the side, you’re not actually going to do anything, you almost want to be at 90 degrees, and it ends up being really difficult. Okay, so in those instances, when you’ve got an internal connection, the implant actually needs to be deeper. So you’ve got running room to have a natural emergence, but then you need to condition the soft tissue with a, instead of just a standard healing abutment out of the pocket, you can make custom healing abutments so you get a really nice smooth transition. Okay? Now, the reason why that is important, is because when you’ve got a very acute and sudden emergence angle A) it becomes virtually impossible to probe to the neck of the implant, but it actually answers the bio flora, the biofilm next to the implant neck itself, unfavorably, it becomes anaerobic as opposed to aerobic. Okay? So you’ve actually snookered yourself. So because what you’ve done is you’ve created a situation where you need to probe but it’s actually difficult to probe. Okay? So the other way of doing it is once you place your implant deep enough, the way that I do it, is I use external hex and I use quite wide implants. Because then it’s…

[Jaz]
Only because I think everyone’s like listening like wow, they’re like gripped by this because this is very interesting in terms of the different connections and how to have that runway room to get the best emergence profile. But like if I’m a GDP and which I am, and I see a patient and implant was put in, I don’t place implants. So patient comes in, they got an implant. I’m not going to pause and say, Okay, what kind of connection is that? Now I will because it’s great point you raised. Now I look at the radiograph and I’ll see okay, is this a lollipop or is this not a lollipop? And then but you know, what am I gonna do?

[Pav]
Okay, fine. That’s exactly the point that I was getting to. So first thing that you do is you take a radiograph. Okay, if it looks like a lollipop, there’s not really much point in trying to do it because the angle that you’ve got to get to, the pressures that you’ve got to apply, you’re not really going to be able to approach the neck of the implant, okay?

[Jaz]
Of course.

[Pav]
And now it is my opinion that you know, if you can get to the neck of the implant, you should be probing to the neck of the implant, okay? So you don’t want to do it too aggressively, it should just be very gentle pressure, okay? And what you’re looking for is you’re looking for the same thing as what you would do when you have a tooth. Is there suppuration? Is there bleeding? Okay? Not so much about the depth of the probing itself, okay? Because you don’t have a true periodontal attachment. It’s like a long junctional epithelium. So you’re applying much lighter pressure, you’re automatically going to have pseudo pockets going deeper. But the question is, Is it bleeding? Is there suppuration? And as I said, is if you’ve got this lollipop type appearance, so you’ve got this skinny implant, all of a sudden, really, really big crown on top, I don’t think you can probe those pretty well. So why bother?

[Jaz]
Still probing just to check if there’s bleeding or suppuration?

[Pav]
So no, I mean, the test that you can do in that area is you look at your radiograph to see A) is there any bone loss around the threads? We’re gonna come back onto that in a minute, because I know that’s one of the topics, Okay? The next really, really, really good test is just with a finger, just push the gingiva either side, because if you push the gingiva, either side, you see suppuration coming up one side, that’s a problem. Makes sense?

[Jaz]
I see. So you’re kind of like milking the implant.

[Pav]
Yeah, massage. Exactly what it is. If you’re massaging the gingiva, either side, and you’ve got bleeding, or you got pus coming out without even picking up a probe, that’s a problem, that’s absolutely a problem. Okay? So let’s say you’re looking at the radiograph and you get this nice transition from the implant to the crown, it just looks like nice and smooth. Yeah, pick up a probe, it’s not a problem, just don’t be heavy handed with it. So what you’re not trying to do is you’re not trying to sound down to the neck of the implant, lots of bone, all you’re doing is you’re just going kind of like into the cuff a little bit, you just go into the cuff and just sweeping it backwards and forwards. And you seeing whether that triggers any bleeding, because that’s a sign of inflammation. So there’s not so much probing is you just seeing whether it triggers an inflammatory response, that’s all that it is. But you what you will notice as well is particularly with implants, is you get this little purpley band around the neck of the implant when in early stages of inflammation. So and in those instances, when you’re looking at those perfectly bands should immediately be thinking to yourself, something may not be quite right here. Okay? So I have no problems with people gently probing if you could use a plastic probe that’s better. You got a metal probe, you know, there’s not too much data to go in between because it swings and roundabouts. If you don’t probe, you don’t know what the problem is. If you do probe, but you probe too hard, you’re going to scratch things, you’re unlikely to get to the neck of the implant, or you shouldn’t be able to get to the neck of the implant. I think it also comes into play, what restorative material has been used as well. Okay? So without going too much into it, there is a very good researcher called Tomas Linkevičius, he has done a fantastic textbook called Zero Bone Loss Concepts. He teaches on it. And the restorative protocol that he use is highly polished zirconia on the fit surface against the soft tissue itself. And when you do that, and when you autoclave it and clean it properly, you actually get soft tissue adhesion to the neck of the implant. Okay? So allow me to break this down a little bit more. I know we’re going a bit more advanced, but it’s actually really relevant for what we’re talking about. He did once a day where he did restored single implant crowns. Okay? Using Zirconia. On half of the fit surface against the soft tissue, he used a zero bone loss concept which is highly polished, no glaze, okay? On the other half of the same implant, he used glaze over the surface, and if it’s, and six months later, he programmed the implant, okay? The average probing depth of the polished area was one to two millimeters, the average probing depth around the glazed area was two to four millimeters. So you can actually get a division of the soft tissue onto the surface of an implant if you do it properly. So I think it’s also important to know what material has been used, okay? Because if it’s a PFM, you’re not going to get that adhesion, you need to be much more gentle with your probing technique. The other thing that you can do as well is if you’re going around is as you put the probe in, you take it out and you wipe the probe clean with a clean gauze so you’re not transferring bacteria from one position of the implant to another.

[Jaz]
Wow okay that is a dedication.

[Pav]
Yeah, that’s dedication. But you know that’s something that I heard, but then I thought so that, you know, then I was thinking to myself, you know, you’re talking about not transferring bacteria from one part of an implant to the other, it still sat underneath the implant. It’s still a problem, right? So it’s a, and this is why I’m saying that there’s no 100% correct answer. But I think what you need to do is you need to look at the radiograph. And make an appropriate decision. If you see that lollipop on a stick, you’re not going to get to the neck, forget about it. If it looks like a really nice, what we call emergence profile, that really nice, soft, flowing type thing, then you think to yourself, yeah, I’ll gently probe this. And to be honest, is if I have, like my own implant crowns, now, the zirconia ones, I’m less bothered about probing them, because I know I’m going to get soft tissue adhesion. So I look at the adjacent teeth as well, right? So if the patient’s cleaning everything really, really, really well, you’re unlikely to have a problem with the implant. So don’t take the implant as a standalone thing. Look at everything else around it as well.

[Jaz]
Well, before we now come on to the radiograph, because you touched on that and that was it. Next question about the thread exposure and what is a normal bone loss before I get to that, I mean, when you find if and when you find bleeding, when you’re doing the probing on implant, I think that lends itself to a diagnosis of Peri-implant mucositis I believe pus would mean, I know it might not be a hard and fast rule, but pus usually what I’ve been taught and I’ve read Peri-implantitis. Should I be referring to someone who’s more clever than me in implants? Every time I diagnose Peri implant mucositis, just bleeding or just simple local measures? Improving OH is enough or do you think I should be actually sending him back to the dentist? So Peri-implantitis with pus I definitely would be not, I would not be ignoring that.

[Pav]
Yeah. Local measures. So improve the oral hygiene, explained to the patient what’s going on. And just treat it like a Perio case. So you’re monitor it over. And you assess it over a number of months. And it is really important that the patient improves because the other issue that you have is the crown cement retained and is it cement underneath that’s causing this in which case, no amount of oral hygiene, you can do this. And what the data shows is if you do a cement retain crown and you can’t get rid of the cement, the cement may cause an issue seven to eight years later, sometimes it’s not straight away. So you know, a lot of people are doing well, there’s nothing wrong with cement retained crowns. And you look at this paper and it goes Oh, yeah, you know, after three years, cement retained crowns, I’ve got no issues. There’s that Yeah, but the peri-implant cementitious can be triggered seven or eight years after when you actually cemented it. So I think it’s important to see whether there’s a scratches in it. If there’s scratches in it, then you know, it screw retained. If there’s no screw access, and it just looks like a normal crown, then it’s cement retained. And then we come back to the original issue that we spoke about, if you’ve got this lollipop type thing, being able to get a probing towards the neck of the implant to get rid of all of the cement, never, it’s not going to happen, there will 100% be cement there. So when you have just a little bit of local inflammation, by all means start local measures first, really good OH, there are some products called blue®m, okay? I think that there’s a mouthwash, there’s a gel, they actually worked really nicely. They are oxygenating, they’ve got oxygen in it, and it is ` the biofoam for that to be more favorable. And what you should notice is once you implement those measures, it should maintain, like with gingivitis may get the odd flare up now and again, but you shouldn’t have anything persistent.

[Jaz]
For me your word is gospel, you know, for me, you’re the guy who doesn’t you know, if you don’t know something, it’s not worth knowing when it comes to implant. So I will definitely look into that product for, to help my patients supportively but on to question two now.

Jaz’ Outro:
There we have it, guys. Hope you enjoyed that group function on can you probe that implant? The next one is going to ask about what is the normal amount of bone loss around an implant? So as a GDP when I see a radiograph, a PA, and I’m seeing a little bit of bone loss around an implant, Should I be worried? I don’t know at what point I should be referring on to the person who placed the implant or someone who a periodontist maybe? So that’s the kind of flavor I got. And the third question which all be covered in part two of this group function is what do you do when you get an implant screw loosening? So as a GDP if someone’s implant crown is loose, I now know what that is a screw loosening. You can hear about our use of thing that was but it’s a screw loosening. And is it cool for me to just enter the access cavity and just Yeah, finger tight or tighten it to what I think it should be torque to, is that a good thing to do as GDP? Well, you’ll find out very soon, either a few days or a week, depending on my workload. But anyway, thank you so much for supporting and listening. I really appreciate it. I’ll catch you in the next one.