Differences in Dental Implant Maintenance and Training in Germany and Israel

© graphixchon / Adobe Stock

In the United States, the Commission on Dental Accreditation (CODA) sets accreditation standards for dental education programs, including dental hygiene. Despite these standards, not all dental hygiene programs are exactly the same because not all dental hygiene program directors or instructors are exactly alike. The knowledge a dental hygiene professional (DHP) has regarding patient care protocols, treatment modalities, current research, and the like also vary due to many factors, such as the continuing education courses each individual takes or how well a DHP actively engages in lifelong learning.

While no two DHPs are alike in the United States, the same can be said for DHPs in other countries. Have you ever wondered about treatment protocols in different countries or how DHPs differ in their treatment protocols in different countries? Researchers from Goethe-University, Frankfurt, Germany, and Tel Aviv University, Israel, set out to do just that in a study published in the International Journal of Dental Hygiene.1

Their research aimed to assess the common practices of DHPs in Germany compared to Israel regarding training on implants in educational programs and implant maintenance to determine differences in practice.

Background on Dental Hygiene Practice in the European Union

Before getting into the research results, a bit of background on dental hygiene practice in the EU might be advantageous. The researchers state, “The work of DHPs is structured differently within the European Union (EU) and in countries of EFP [European Federation of Periodontology] member societies. In 18 EU member states, dental hygienists’ occupational licensing is regulated, while in eight member states (Austria, Bulgaria, Estonia, France, Germany, Luxemburg, Romania, and Cyprus), it is not. Beyond regulations, there may also be differences in education/training regarding peri-implant diseases.”1

As of September 2020, the Israel Central Bureau of Statistics reported the Israeli population was 9.4 million, and in 2020 the number of DHPs was 2663. “In Israel, dental hygienists’ education consists of two full years, or 2000 academic hours, undertaken in one of the four educational institutions recognized by the Ministry of Health. To practice as a DHP, obligatory licensure examinations must be performed.”1 DHPs in Israel must practice under the supervision of a dentist.1

In 2020, Germany’s population was approximately 82 million. “In September 2019, 1820 dental hygienists received education in Germany, of whom 1646 (90%) completed education as a dental assistant and later received a dental hygienist professional certificate after further education. In total, 174 DHPs (10%) had completed a bachelor’s degree in dental hygiene.”1 In Germany, only dentists are allowed to practice dentistry, though they can delegate certain defined treatments to DHPs. DHPs must practice under the direct supervision of a dentist.1


The researchers used an online questionnaire created by the Periodontology Departments of Goethe-University, Frankfurt, Germany, and Tel Aviv University, Israel. Distributed via social media by DHP associations, the questionnaire collected information on the demographics, training, prevention, and treatment of peri-implant diseases in both countries. The total responses to the questionnaire that were included in the research analysis were 376 DHPs, 169 from Israel, and 207 from Germany. It’s worth mentioning that most participants were female and had received education and worked in their home countries.1

Summary of Results (not all results from the questionnaire are listed)

Implant Maintenance and Treatment Education

During their primary education:

German DHPs Israeli DHPs
Received training in treatment of peri-implant infection 82% 59%
Treated peri-implant infection 72% 41%
Used mechanical (i.e., instrumentation) and/or chemical (i.e., chlorhexidine irrigation) implant treatment therapies 62% 46%
Did not perform any treatment of implants 15% 38%


Implant Assessments in Practice German DHPs Israeli DHPs
Reported the symptoms of peri-implant infection are redness, edema, exudation/bleeding, mobility, and recession 71% 67%
Plaque, bleeding, and probing depths are assessed 74% 67%
Do not assess plaque, bleeding, or probe depths 1% 5%
Routinely monitor implant health with radiographs 56% 17%
Only take radiographs if problems are assumed 43% 43%
Do not take radiographs of implants 1% 40%
Do not probe implants at all* 5% 22%
Use metal probes on implants 33% 49%
Use plastic probes on implants 44% 22%

*Researchers state, “Occasional peri-implant probing at low force (0.25 N) does not harm peri-implant tissues, similar to periodontal probing, which does not harm periodontal tissues. However, the benefits and therapeutic consequences of peri-implant probing as well as BOP are still debated.”1

Oral Hygiene Instruction given to Patients with Implants German DHPs Israeli DHPs
Education given about risk factors that contribute to peri-implantitis 98% 94%
Provide oral hygiene instruction at each maintenance appointment independent of oral health status 73% 66%
Give no oral hygiene instruction at all 4% 0.6%


Treatment of Implants German DHPs Israeli DHPs
Do not perform hand instrumentation 8% 1%
Perform subgingival instrumentation 56% 86%
Use steel instruments 23% 80%
Use titanium instruments 30% 14%
Use plastic instruments 23% 28%
Do not use devices other than hand instruments

(i.e., prophy jet)

2% 77%
Do not use ultrasonics 23% 19%
Use prophy jet with or without nozzle 96% 18%
Use laser 14% 1%

In Closing

Despite advancements in dental care, many people suffer tooth loss. This is mainly caused by dental caries, injury, or periodontal disease. For many years, bridges, partials, and dentures were the only way to replace missing teeth. But today, dental implants are available, and placement is increasing.

According to a 2018 study, the prevalence of dental implants increased from 0.7% in 1999 to 5.7% in 2016 in the United States.2 According to the researchers of this summarized study, “3.4% of individuals aged 35–44 years, 8.1% aged 65–74 years, and 8% aged 75–100 years presented with dental implants” in Germany.1

“With increasing numbers of dental implants inserted and the mean prevalence of peri-implant mucositis and peri-implantitis of 43% and 22%, respectively, these diseases represent growing oral health problems. The prevention and treatment of peri-implant mucositis consequently prevent peri-implantitis.”1

The researchers conclude further information regarding DHPs training on implants in educational programs and implant maintenance to determine differences in practice should take place in other countries.1 Perhaps a similar study in the United States should take place and focus on the differences between each state. Knowing where dental hygienists are in their implant knowledge and how they maintain the oral health of patients with implants could guide what education they may need. This data could not only help guide CODA accreditation standards of dental hygiene programs but also guide state dental boards on required continuing education courses.

Lastly, I will conclude with this: What I found especially profound that the researchers stated in this study was, “Considering the high prevalence of severe periodontal diseases, the prevention, treatment, and maintenance of periodontal diseases can only be provided at the population level if dentists are supported by dental hygiene professionals.”1 Dental hygienists are necessary, indeed.

Before you leave, check out the Today’s RDH self-study CE courses. All courses are peer-reviewed and non-sponsored to focus solely on high-quality education. Click here now.

Listen to the Today’s RDH Dental Hygiene Podcast Below:


  1. Eickholz, P., Winkler, P., Elez, I., et al. Common Practices of Dental Implants Maintenance among Dental Hygiene Professionals in Isreal and Germany. International Journal of Dental Hygiene. Aug 2022: Epub ahead of print. https://onlinelibrary.wiley.com/doi/10.1111/idh.12612
  2. Elani, H.W., Starr, J.R., Da Silva, J.D., Gallucci, G.O. Trents in Dental Implant Use in the U.S., 1999-2016, and Projections to 2026. Journal of Dental Research. 2018; 97(13): 1424-1430. https://pubmed.ncbi.nlm.nih.gov/30075090/
Previous article5 Strategies to Reduce Wait Time for Exams
Next articleMeeting the Dental Hygiene Needs of Geriatric Patients
Kara Vavrosky, RDHEP
Kara Vavrosky, RDHEP, is a co-founder and the chief content officer of Today’s RDH, an independent educational publishing company for dental hygienists, encompassing articles, a podcast, virtual continuing education events, and self-study continuing education. Today’s RDH was launched in 2018 after Kara built her social media presence with her largest following on her Facebook page, Dental Hygiene with Kara RDH, which was created in 2013. An Oregon Institute of Technology graduate, Kara has a deep passion for spreading knowledge about the importance of oral health and its association with systemic health. Kara’s passion extends to helping other hygienists understand current protocols and evidence-based research – all with the goal of lifting dental hygienists and the dental hygiene profession. Kara was recognized in 2020 as one of the Top 100 Women in Media for her entrepreneurship as a co-founder of Today’s RDH. In 2022, she was recognized by the American Dental Hygienists’ Association for their Standout Seven Award in the Entrepreneur category. Kara lives in Vancouver, Washington, just outside Portland, Oregon, with her husband, Ben, and their four Chihuahuas. When she’s not working, Kara loves riding the Oregon Dunes on her quad, spoiling her Chihuahuas, and spending time with her close-knit family.