My Implant Hurts or Feels Loose. Can It Be Saved?

An implant that has been comfortable for years and is suddenly sore, or that moves slightly when you chew, is worth having looked at quickly. Not because the situation is usually dire, but because the two possibilities behind those symptoms are very different from each other, and one of them gets worse while you wait.

Is It the Crown, the Screw, or the Implant?

An implant restoration is three parts: the titanium post in the bone, the abutment that connects to it, and the crown you see. Movement can come from any of the three, and working out which is most of the early diagnosis.

A loose crown or abutment screw is a mechanical problem in a part designed to be serviceable. A loose implant is a biological problem in a part that was not. To the patient they can feel identical, which is why guessing is unhelpful and a short examination is not.

What Does a Loose Crown or Abutment Screw Mean?

Usually that a small screw has backed off, which is common, unalarming, and generally an easy fix. Screws loosen because chewing forces work on them over years, because of grinding or clenching, or because the bite has shifted as other teeth moved or were restored.

The repair is often straightforward: the crown is removed or accessed through a small opening, the components and the fit are checked, the screw is retightened to the correct torque, and the opening is sealed. A fractured screw is retrieved and replaced. If the bite caused it, the bite is adjusted or a night guard made, because a screw that loosens repeatedly is telling you about forces rather than about screws.

The reason not to ignore a loose crown is that continued movement can fatigue and fracture the screw and, at worst, damage the internal threads of the implant itself. A small problem handled promptly stays small.

What Does It Mean If the Implant Itself Moves?

An integrated implant is locked into bone and does not move at all, not even slightly. Movement of the implant body means the bond between bone and implant has been lost across a meaningful part of the surface, and unlike a loosened screw, that cannot be tightened back.

An implant that is genuinely mobile is, in nearly every case, removed. Removal is usually far less involved than patients imagine, and it is generally not the end of the plan for that space. What it is not is something to monitor for a few months.

Mobility in the first weeks after placement, before the implant has ever carried a crown, is a different event called early failure: the implant never integrated. It is uncommon, and it is usually followed by healing the site and trying again once the bone has recovered.

What Is the Difference Between Peri-Implant Mucositis and Peri-Implantitis?

These are the two stages of infection around an implant, and the difference between them is the difference between a cleaning and a surgery. The American Academy of Periodontology draws the line the same way: mucositis is inflammation found only in the soft tissue around the implant with no sign of bone loss, while peri-implantitis involves deterioration of the bone supporting it. Neither is rare. A meta-analysis by Derks and Tomasi found mucositis in roughly 43 percent of patients with implants and peri-implantitis in roughly 22 percent.

Peri-implant mucositis is inflammation confined to the gum. The tissue is red or puffy, it bleeds when brushed or probed, and there may be a bad taste. No bone has been lost. At this stage it behaves much like gingivitis around a natural tooth and is reversible with professional cleaning around the implant, a change in home care technique, and sometimes removal of a cause such as cement left under the crown years earlier.

Peri-implantitis is the same inflammation after it has reached bone, and bone lost around an implant does not grow back on its own. Pockets deepen, pus may appear, the gum may recede to show a gray edge of metal, and in advanced cases the implant loosens. Treatment is possible and often successful at stopping the process, but it is considerably more involved.

This progression matters because it is quiet. A natural tooth has a ligament full of nerve endings that complains early. An implant sits directly against bone with no ligament, so pain arrives late, often after substantial bone is gone. The signs of implant infection covers the early symptoms, most of which are things you notice rather than things that hurt.

What Happens at the Evaluation?

A worthwhile assessment takes a single visit and involves four things.

Probing. A periodontal probe is walked around the implant to measure pocket depths and record where it bleeds. This is the measurement that separates gum inflammation from bone loss, and it is why a visual check alone is not an answer.

X-rays. A periapical X-ray taken at the correct angle shows the bone level along the implant and, compared with the film taken when it was placed, how much has changed and how fast. Where a flat image is not enough, a 3D scan shows bone on the cheek and tongue sides, which a standard X-ray cannot.

A mechanical check. The crown is tested for movement separately from the implant, the bite is examined, and the components and any retained cement are inspected. This is the step that separates a loose screw from a loose implant.

History. Smoking, diabetes control, grinding, the design of the restoration, whether it can be cleaned at home at all, and how long symptoms have been present. Peri-implantitis usually has a cause, and treatment that ignores the cause does not last.

What Treatment Is Possible at Each Stage?

Mucositis, no bone loss. Professional cleaning around the implant, correction of whatever is trapping plaque, coaching on technique with floss or a small interdental brush, and a shorter recall interval. This is the stage worth catching.

Early to moderate peri-implantitis. Access to the implant surface, thorough decontamination of the threads, and often a bone graft, with or without a membrane, where the shape of the defect allows it. Some defects hold graft material well and some do not. Where rebuilding is not realistic, the alternative is to reshape the site so it can be kept clean and to monitor it closely.

Advanced peri-implantitis. When most of the implant’s length has lost its bone support, or when the implant is mobile, treatment shifts from saving it to planning the space.

Surgery around implants can be done with local anesthetic alone or with nitrous oxide, oral sedation, or IV sedation; sedation explains the options, and implant problems goes through each treatment in more detail.

When Does an Implant Have to Come Out?

The common reasons are mobility of the implant body, bone loss so advanced that nothing stable remains to rebuild against, a fracture of the implant itself, infection that has failed to respond to treatment, or an implant positioned so poorly that a cleanable, functional restoration was never going to be possible on it.

Removal today is usually a smaller event than patients expect. A failed implant is often loose enough to lift out, and where it is not, reverse-torque instruments back it out with the surrounding bone largely preserved. It is typically an appointment under local anesthetic, with or without sedation, and the recovery resembles an extraction more than the original surgery.

What Happens After an Implant Is Removed?

Usually the site is cleaned thoroughly and grafted at the same appointment, because bone lost to infection needs rebuilding before anything can be placed there again, and grafting at the time of removal preserves the ridge shape. That graft then needs months to mature, commonly four to six, longer where the defect was large.

A replacement implant is possible in many cases, and whether it is right for a given patient depends on how much bone can be rebuilt, why the first one failed, and whether that cause can be controlled. Replacing an implant without addressing uncontrolled diabetes, continued smoking, unmanaged grinding, or a restoration that cannot be cleaned is how a second one follows the first.

Where a replacement is not the best plan, the options are the ones considered before any implant: a bridge, a removable partial denture, or leaving the space, each with real trade-offs. A temporary is generally made so nobody walks around with a visible gap during the healing months.

What Warrants a Same-Day Call?

Call the office the same day for any of these:

• Pus around the implant, or a swelling on the gum that drains
• Facial or jaw swelling, or swelling that is increasing rather than settling
• An implant or crown that moves when you touch it or chew
• New pain on biting on an implant that has been comfortable
• Fever together with any of the above
• A numb lip or chin that was not there before

Sooner rather than later, but not an emergency: bleeding when brushing around the implant, gum that has receded to show metal, a persistent bad taste from one spot, or an implant that feels subtly different from how it used to.

During office hours, Monday through Thursday, 7:00 AM to 3:00 PM, the number is (512) 346-6097, and urgent problems are seen the same day. Urgent problems explains what happens when you call.

What If the Implant Was Placed Somewhere Else?

That describes a large share of the implant problems Dr. Verrett sees, and it is not awkward. Austin Periodontal Associates treats implants placed elsewhere on the same terms as its own, and second opinions are welcome, including from patients who simply want an independent read on advice they have already been given.

Bringing the original X-rays or placement records helps, because the most useful measurement is not the bone level today but how much it has changed since the implant went in. If you cannot obtain them, the practice can request them, and a current set of images is taken regardless.

Dr. Verrett is a board-certified periodontist and a Diplomate of the American Board of Periodontology, practicing in North Austin. An evaluation of a troublesome implant is an examination and a conversation, not a commitment to treatment, and it starts with a consult.

The consensus report of the 2017 World Workshop, published by the American Academy of Periodontology, separates peri-implant health from mucositis from peri-implantitis by bleeding on probing, swelling and suppuration, and progressive loss of supporting bone.

An implant that is failing is easier to treat the earlier it is caught, and this office sees implants placed elsewhere as readily as its own. Request a consult in North Austin, or call (512) 346-6097.