How to Clean All-on-4 and All-on-6 Bridges: Daily Care and Reviews

Why cleaning matters with a full-arch bridge

The 2017 World Workshop consensus describes peri-implantitis as a plaque-associated condition²: inflammation of the tissue around an implant with progressive loss of the supporting bone. Inflammation limited to the soft tissue, without bone loss, is called peri-implant mucositis. Treating peri-implantitis may need surgery, and if it progresses the implant can be lost.

It is not rare. Reviews of full-arch bridges report it in 4 to 18 per cent¹ over 5 to 15 years of follow-up; the summaries do not say whether that counts patients or implants. A 57-study review of implant patients in general found it in about 20 in 100 patients³. The rate depends on the definition used and how long the implants have been in place. After past treatment for periodontitis, gum disease that has damaged the bone around the teeth, peri-implantitis was about 3 times as common⁴, and the rate of implant loss over follow-up was about 1.75 times higher (a hazard ratio).

A fixed bridge adds its own difficulty. It covers the gum where the teeth used to be, and food and plaque collect between its underside and the gum. The line where the bridge meets the gum is the hardest place to keep clean. Because the bridge is screwed in, only your dentist can remove it. The All-on-4 and All-on-6 pages explain both designs.

A daily routine

Your dentist shows you the routine on your own bridge, because the space under each bridge is different. The usual parts are these:

• Brush twice a day. UK prevention guidance advises brushing at least twice a day⁵ with fluoride toothpaste and spitting it out; thorough brushing may take at least two minutes. Use a small-headed brush with soft or medium bristles, not hard ones, and angle the bristles towards the line where the bridge meets the gum, on the cheek side and on the tongue or palate side.
• Clean under the bridge once a day. Thread bridge floss (floss with a stiffened end) under the bridge and around each implant, or pass an interdental brush of the right size between the bridge and the gum. A water flosser can also reach under the bridge. Your dentist shows you which works in your mouth and which brush size fits. If floss catches or shreds at one spot, stop using it there and tell your dentist.
• Check in a mirror. Redness, swelling or bleeding along the gum line can point to a place you are missing.
• Protect the bridge. If you clench, a night guard may be advised. It has not been shown to prevent implant loss; its purpose is to protect the bridge.

In the weeks after surgery, while a provisional bridge is in place, follow the written aftercare instructions you are given. Cleaning around the healing gum is gentler at first, and your dentist tells you when to move to the full routine.

What the evidence says about the tools

Most studies of home cleaning were done on natural teeth, not under full-arch implant bridges. They are a guide, not proof for your bridge.

• Powered or manual brush. A Cochrane review of 51 trials found that powered brushes reduced plaque and gum inflammation slightly more⁶ than manual ones, with moderate certainty. How much that difference matters is unclear, and both kinds remove plaque.
• Floss and interdental brushes. A Cochrane review of 35 trials found that floss added to brushing may reduce gum inflammation⁷, and that interdental brushes added to brushing may reduce plaque. The certainty was low or very low, and the differences may not be clinically important. Where they fit, interdental brushes may reduce inflammation more than floss.
• Water flossers. We found no study in our sources comparing water flossers with other tools under full-arch bridges. There is no good evidence in our sources that one of them is better.
• Mouthwash. Chlorhexidine mouthwash reduces plaque. In people with mild gum inflammation, though, its effect on the gums was not considered clinically relevant⁸. It stains teeth and can alter taste and irritate the mouth, so it is advised for short periods only, when your dentist recommends it. No mouthwash replaces cleaning under the bridge.
• Toothpaste. We found no study in our sources comparing toothpastes on implant bridges. Ask your dentist which suits the material of your bridge.

Professional reviews and cleaning

Daily cleaning is one part of the care; regular reviews and professional cleaning are the other. Tell your dentist if you smoke or have diabetes so that both are taken into account, and ask your doctor for support if you want to stop smoking.

• A baseline. When the bridge is completed, an X-ray and probing measurements are taken as a baseline². Later changes around the implants are judged against that record.
• A programme, not a fixed date. The European Federation of Periodontology guideline calls for a structured supportive care programme⁹, with regular assessment, once implants are in use. The NICE guideline on dental recall recommends that the interval between reviews be set for each patient¹⁰ according to their risk; that guideline covers check-ups in general, not implants. There is no single interval that suits everyone; yours is given in writing.
• What is checked. The gum around the implants is checked for bleeding and swelling, and the bridge, its screws and your bite are checked. X-rays are taken when needed, and your cleaning is reviewed with you.
• Removing the bridge. Because the bridge is screwed in, the dentist can remove it when cleaning or repair needs access underneath.
• How it is cleaned. Hand instruments, ultrasonic instruments and air polishing are used around implants. A review of trials in gum and implant maintenance found that the two implant trials of air polishing reached conflicting results¹¹, and most of its trials had a high risk of bias. The review could not show which method is better for cleaning around implants.

When to see a dentist

Do not wait for your next review if you notice any of these:

• Bleeding, a bad smell, discharge or receding gum around the bridge
• Food packing under the bridge in a place you cannot clean
• The bridge moves, a screw feels loose, or a piece cracks or breaks
• Pain on biting, or a bite that feels high
• Nasal discharge, blockage or sinus pain (upper jaw)

Emergencies. Difficulty breathing or swallowing, rapidly spreading swelling of the face or neck, high fever or swelling around the eye are serious signs. Do not wait for the clinic's reply: go to the nearest emergency department or call 112.

Frequently asked questions