The long time gone since graduation may explain why almost half of the participants in this study did not receive formal training on dental implant maintenance. Dental implants may not have been part of their curriculum at undergraduate levels.
Humphrey noted that dental implants have become an integral part of dental reconstruction and quotes that approximately half a million dental implants are placed annually in the United States of America.  Although there are no available data estimating the exact number of dental implants integrated each year in Libya, it was reported that half of the partially edentulous Libyan patients opted for dental implants when a definitive tooth replacement modality was considered.  Accordingly, it is necessary that implant clinicians have the most current knowledge for the maintenance of dental implants.
One of the earlier articles to discuss implant oral hygiene maintenance appeared in 1990 and emphasized the importance of patient oral care throughout the continuum of pre-surgical, surgical, and restorative/maintenance phases of treatment.  The authors emphasized that a thorough periodontal assessment should be performed prior to implant surgery. In addition, patients must be trained in an appropriate oral homecare program before the implants are placed, and then placed in a maintenance regimen at appropriate intervals after implant placement.
The rationale for this emphasis on proper oral care is a simple one. During the healing phase, for example, it is essential to prevent the development of an inflammatory response around both the natural teeth and any implant surgical site. An inflammatory process will interrupt the normal healing process and jeopardize osseointegration of the implants. At the first follow-up, during the first week following surgery, a plastic curette can be used to gently debride the adjacent teeth of plaque and Materia Alba to maintain a healthy biological environment.
When sutures are needed to secure soft tissue, additional instructions may need to be given to the patient, because sutures can make it more difficult to maintain oral hygiene. It may be very helpful to advice patients not to use a dental brush to clean the implant site. Instead, a Q-tip soaked in the chlorhexidine gluconate solution, can be used gently to wipe across the surgical area in a facio-lingual direction.
Also, it is advisable to record the number and type of sutures placed to ensure all suturing materials are removed at the appropriate post-operative appointment which usually takes place at the second follow-up ten days to two weeks after surgery.
In case of a single stage procedure, where healing abutments (Soft tissue formers) are projecting through the mucosa, the follow up visit should include evaluating the color and consistency of soft tissue around. Special instructions may be necessary when there is a limited mesio-distal space and the healing abutment is therefore located close to a natural tooth. This proximity may restrict access for hygiene procedures due to limited space between the abutment and adjacent tooth/teeth.
If a temporary restoration was immediately connected to the implant (Immediate Temporization), care should be taken if a motorized tooth brush is routinely used not to apply too much mechanical motion on crown. It may be wise to use manual gentle brushing and flossing instead. It is usually helpful at the 1 week follow up visit to verify tightness of the temporary abutment screw and that neither occlusal nor proximal contacts are encountered.
In this study, only 10.5 % (n=4) of clinicians schedule there patient for follow up during the first week of implant placement. It may be prudent to see patients of dental implant one week to 10 days after surgical integration to confirm proper hygiene measures and to maintain healthy peri-implant mucosa.
This study revealed that only 11 participants (28.9%) schedule implant patients for maintenance every month after implant placement. The main purpose of this appointment is to ensure oral hygiene procedures are being effectively implemented. If adjustments or oral hygiene reinforcement are required at this pre-prosthetic appointment, then it is prudent to schedule another 1-2 week visit before loading the implant with a definitive coronal restoration.
Following treatment completion, the patient should be seen several times during the first year since there are no guidelines regarding the time intervals of care that optimize peri-implant health. 
This study has shown that only 25 (65.8%) of surveyed participants schedule there patient for implant maintenance after prosthesis delivery. However, patients should be seen during the first 1-2 weeks after crown placement. The main purpose of this appointment is to ensure oral hygiene procedures are being effectively implemented. This appointment also serves another purpose. It allows the restorative dentist to decide if desired occlusal relationships were attained or if additional modifications are necessary. While in the office, the patient should be encouraged to ask any questions that may have risen since the last visit and especially now that treatment is complete. This early post-prosthetic appointment is particularly important when crowns are cemented over abutments as invisible cement residues can serve as a documented cause of peri-implant disease, this includes fistulas/fenestrations as well as bone loss and consequent implant loss. Figure 1
Once the results of the initial post-prosthetic appointments were reasonable, the patient need only to be arranged for a 3-month follow-up dental hygiene appointment. This timing seems applicable because it has been shown that plaque-induced peri-implant mucositis can develop in a 21-day period, if no oral hygiene procedures are accomplished. 
Therefore, if the patient’s oral hygiene practices truly are inadequate during this first 3-month period, those signs will be detected early and corrective measures can be employed in a timely manner. Furthermore, a decision can be made as to the need for continuing a 3-month recall schedule or whether 6-month recall intervals can be used. If there is any doubt about the patient’s maintenance practices, a 3-month recall schedule should be maintained. Our study revealed that only 10 (26.3%) of questioned clinicians schedule their patients for follow ups after 6 months of prosthesis delivery.
Despite the evidence-based data reporting that most implant losses occur during the first year of function,  only half of the participants schedule their implant patients for follow ups during this time interval.
Regarding the items to be evaluated at each recall appointment, a previous clinical review  has proposed that each periodic examination should include an assessment of medical and dental histories, soft tissue assessment, plaque score using either of the two implant-specific plaque indices , pocket depth, bleeding on probing, presence of suppuration, stability of soft tissue margins, presence of keratinized tissue, occlusion, mobility, and checking radiographs. This study has shown that 31 (81.5%) evaluate amount of keratinized tissue around dental implants. Minimal keratinized mucosa around implants may show increased mucosal recession, greater plaque accumulation, peri-implant mucositis, and increased bone loss. [15, 16] However, no relationship was found between keratinized tissue widths and implant survival in two literature reviews. [17, 18]
When keratinized mucosa is lacking around implants, the indications for the use of soft-tissue grafting are unclear.  Therefore, it has been stated that preventive surgery should be confined to situations where altered morphology of the peri-implant mucosa affects oral hygiene. 
All of the participants (100%) reported that they evaluate recession around dental implants. Causes of recession may include overzealous brushing, absence of attached mucosa, high frenal attachment, and too buccally placed immediate implants. 
Probing around implants should be considered a reliable and sensitive parameter for the long term monitoring of peri-implant mucosal tissues. 
Disposable plastic probes and replaceable plastic probe tips that screw into autoclavable metal handles have been recommended over metal probes that are being used by more than 70% of Libyan implant clinicians according to this survey. 
Probing depths typically are deeper at implant sites than they are at natural tooth sites. In one report, the average probing depths around healthy implants ranged from 1.3 - 3.8 mm. 
A postoperative radiograph after implant placement is not pertinent with over 20% of the participants. In fact, postsurgical radiographs can serve multiple functions including base line for checking bone level around the implant at maintenance appointments, confirmation of implant positions and angulations, and verification of complete seating of cover screws, healing abutments, or coronal restorations if immediately loaded. Figure 2
Periapical radiographs provide excellent information about the bone levels, particularly when paralleling devices are used. This study results showed that almost 29% (N=11) of clinicians do not check bone level surrounding the implant on a regular basis at maintenance appointments.
Some reduction in marginal bone height will usually be noted on a radiograph during the first year following implant placement with 0.9 mm being typical. However there should be very little, if any, clinically perceptible change after that time.
Regarding scaling instruments, researches indicate that stainless steel metal hand scalers can damage titanium surfaces [25, 26] and, therefore, they are not recommended. In contrast, plastic scalers have proven to be safe and do not damage titanium components. 
An apparent paradoxical finding was reported in one study of plastic scalers where there was an increase in the recorded surface roughness due to deposits of plastic particles and debris on the surface of titanium abutments that altered the surface roughness readings. 
While plastic scalers are kind to titanium surfaces, some clinicians find them to be somewhat bulky or too flexible to use in the removal of hard deposits. Unlike metal scalers, plastic tips lack sharpness which is believed to limit their effectiveness in dislodging larger, hard deposits.
Circumventing these limitations of plastic scalers has been achieved in different ways. When larger accumulations of hard deposits are present, some clinicians carefully use metal scalers initially. It is only after removal of the bulk deposits that they switch to plastic scalers for the final surface scaling. Others feel conventional metal scalers can be used to remove calculus and only leads to minor surface scratching of supra-mucosal surfaces when used carefully. However, there is no scientific evidence to support these concepts. These are considered empirical finding but, nonetheless, recommendations based on years of clinical experience. Some clinicians have also reported wrapping a metal scaler with gauze to remove calculus and in so doing reduce the risks of scratching or gouging of the implant surface.
Fiber reinforced graphite scalers (Premier® Implant Scaler; Premier Products Co., 1710 Romano Drive, Plymouth Meeting, PA 19462; www.premusa.com) have been found to produce significantly less roughness compared to stainless steel scalers, and they are deemed to be appropriate instruments to use for scaling procedures. 
It has been shown that titanium hand scaling instruments removed very little substance from the head of implants and from titanium abutments, leaving “virtually no traces of use”.  Nonetheless, it seems prudent to use care with any hand instrument made of material harder than plastic to remove deposits around single implants. Light pressure strokes should be applied along with careful adaptation of the instrument to the cervical contours of the crown. When used in accordance with these guidelines, titanium tipped curettes can remove adherent plaque and calculus deposits effectively without damaging the implant metal surfaces or causing excess soft tissue trauma.
Negative surface changes (scratches, depressions, removal of surface metal) have been found from using metal ultrasonic scaler tips on titanium,  whereas ultrasonic scalers with plastic tips [32, 33] and carbon tips [31, 33] produced no significant surface alteration to titanium surfaces. Therefore, when ultrasonic scalers are used, metal tips should be avoided.
It has been proposed  that a soft rubber tip, not brush, be used around implants in conjunction with an appropriate nonabrasive paste such as aluminum oxide, tin oxide, acidulated phosphate fluoride-free prophy paste, or low-abrasive dentifrice. According to one report, the use of a rubber cup with toothpaste did not affect the integrity of a highly polished titanium surface. 
In another study, when a rubber cup and flour of pumice were applied to a machined titanium surface for five minutes, the microscopic grooves from the titanium machining process were removed, but the surface still was judged to be smooth. 
Others found the use of a rubber cup and a fine abrasive paste to be a safe procedure for supragingival surfaces.  However, using a rubber cup with a coarse prophylaxis paste for 30 seconds removed approximately one-half of a 0.11 mm high ridge of titanium on test samples. 
The use of acidulated fluoride gels should be avoided around dental implants since it has been determined they produce surface degradation of titanium. [37, 38] For this reason, neutral pH fluoride gels should be used when caries prevention is needed in the mouths of patients with dental implants.