This month's clinical tip from the editor: 'The implant you put in my mouth is now bleeding; what should I do?'

This month’s clinical tip from the editor: ‘The implant you put in my mouth is now bleeding; what should I do?’ by Scott Froum, DDS A dreaded phone call that every dental office involved in dental implant therapy may encounter is when a patient calls and says, “Hey Doc, the implant you put in my mouth a few days (or months or years) ago started to bleed.” Most often patients will claim that the problem started “out of the blue” and they tried rinsing their mouths with various medicaments all to no avail.

When dealing with these situations, it is important to first assure the patient that the problem can be addressed and, second, know the etiology behind the problem. Here are the top five reasons why implant restorations can bleed:

1. Cement—If the restoration is cemented, be careful not to extrude the cement into the sulcus. Take a radiograph after cementation to check. Even if the cement doesn’t show on the radiograph, it may be still present on the straight buccal or lingual/palatal and/or the cement may be radiolucent. A study by Wilson (1) suggests that eight out of 10 cementable cases that are bleeding are due to excess cement in the sulcus.

2. Open contacts—Even if your restoration had good contacts when you first inserted the crown, teeth change position over time and craniofacial development continues even in the adult stages of life. (2) In other words, your once-tight contact could have become an open contact. Food impaction is certainly a source of bleeding and the restoration may need to be adjusted or changed.

3. Medications—Medical history and medications have a big impact on the inflammatory nature of the gingiva around teeth and implants. If the patient has a bleeding disorder, a blood dyscrasia, and/or is on anticoagulant medication, increased bleeding may be evident. This type of inflammation, however, must be distinguished from pathologic bleeding.

4. Tissue quality—There is a difference in susceptibility to inflammation depending on the type of tissue surrounding the dental implant restoration. Alveolar mucosa is much more likely to bleed than keratinized tissue when faced with a bacterial challenge. Although studies are equivocal when it comes to the need for keratinized tissue around implants, most authors would agree that having good attached tissue is not a bad idea. A soft-tissue graft is one method of correcting this problem.

5. Iatrogenic—Many patients have the philosophy of the more vigorously I clean, the better it will be. Patients can be their own source of bleeding and problems if hygiene is either not performed in the correct manner, the wrong hygiene products are used for implant hygiene, and/or the hygiene techniques used are too aggressive. Make sure your patients are taught proper technique as well as evaluate them on their home care in a periodic fashion.

MORE CLINICAL TIPS FROM DR. SCOTT FROUM …
This month's clinical tip from the editor: 'Help! My implant fell out!'
This month's clinical tip from the editor: 'How much do you charge for an implant? I just want to know the price!'

Scott Froum, DDS Scott Froum, DDS, is a periodontist in private practice in New York City. He is the editorial director of Perio-Implant Advisory e-newsletter, as well as a contributing author for DentistryIQ and Dental Economics. Dr. Froum is a clinical associate professor at the New York University Dental School in the Department of Periodontology and Implantology, and a diplomate of the American Board of Periodontology. Contact him through his website at www.drscottfroum.com

References
1. Wilson T. The positive relationship between excess cement and peri-implant disease: A prospective clinical endoscopic study. J Periodontol. 2009 Sep;80(9):1388-1392.
2. Daftary F, et al. Lifelong craniofacial growth and the implications for osseointegrated implants. Int J Oral Maxillofac Implants. 2013 Jan-Feb;28(1):163-169.

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