Implantmaintenanceand thedental hygienistsupplement toaccessmay-june 2003
Contents2      Introduction2      The Role of the Registered Dental Hygienist3      History of Implants4      Types of Imp...
Introduction                                implant dentistry allows the dental        bone, surgical procedures such as g...
implant environment. It has been sug-                 According to Terraccino-Mortilla,    Radiographs showed compact bone...
tegration.”44 Osseointegration—incor-      the TMI system. TMI is more invasive             The first consideration is the...
implant, so that is a contraindication      and/or neglect.62 The client who is       alveolar canal that can affect the s...
Treatment Planning                             the restoration. Fees and methods of                                       ...
At stage-two surgery, the implant      when embrasure space permits (Figureis exposed and a healing cuff is placed     8)....
yarn dipped in chlorhexidine or anti-     parallel to the implant surface without             Because the attachment of th...
Maintenance                                or occlusal stress on the implant. All                                         ...
Periimplant mucositis is similar to  Summary                                                gingivitis around a tooth in i...
References                                           Journal of Dental Hygiene 2000;74(3):        25. van Seenberghe D, Be...
38. Meffert R: Maintenance and treatment        52. Astrand P, Engquist B, Anzen B, et al.:       64. Kraut RA, Babbush CA...
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Implant maintenance and the dental hygienist

  1. 1. Implantmaintenanceand thedental hygienistsupplement toaccessmay-june 2003
  2. 2. Contents2 Introduction2 The Role of the Registered Dental Hygienist3 History of Implants4 Types of Implants4 Client Assessment6 Treatment Planning6 Surgical Placement of the Implant7 Restoration of the Implant8 Mucogingival Tissues8 Baseline Data9 Maintenance10 Ailing/Failing Implants10 Summary11 References About the Author This supplement to Access magazine was Sheri Granier Sison, RDH, BS, is clinical sponsored by AIT Dental, instructor and faculty co-supervisor of Hu-Friedy Manufacturing Co., the Implant Clinic at the Louisiana State and Oral-B Laboratories. University Health Sciences Center School of Dentistry. Access—special supplemental issue 1
  3. 3. Introduction implant dentistry allows the dental bone, surgical procedures such as guid- hygienist to function in many of the ed bone regeneration, bone grafts, or Edentulousness is on the decline, stages of dental implant therapy and bone substitutes may be considered.21,22but it will increase dramatically in the help the therapist perform a great serv- A client who meets these criteriaadult population older than 55 years. ice to the client who requires prostho- should be educated about implant den-One study suggests that despite the dontic treatment. This supplement dis- tistry and further evaluated as an10% decline in tooth loss in each of the cusses the indications for dental implant candidate.last three decades, the 79% increase in implants, maintenance and monitoring According to Terraccino-Mortilla,the senior population will result in of implants, and the role of the dental the dental hygienist should develop37.9 million adults requiring one or hygienist in successful implant-based client-specific home care routine fortwo complete dentures in 2020.1 The prosthetic treatment. the implant client.13 This is a dynamicprevalence in tooth loss in the United process, because home care must beStates for adults 18 years or older is altered with each stage of the dental9.7% and increases to 33.1% at 65 years The Role of the implant including post-surgicalor older.2 Missing teeth can cause loss Registered Dental hygiene, provisional restoration, andof self-esteem and have an impact on Hygienist final restoration or prosthodontic deliv-social interaction.3 The diminished ery. In the delivery of oral hygienemasticatory efficiency accompanying Terracciano-Mortilla suggests that instruction, the dental hygienist shouldtooth loss can compromise nutritional the dental hygienist perform a variety also provide client motivation. Tissuestatus, putting clients at higher risk for of duties as a member of the implant destruction in the periimplant site ischronic illnesses like diabetes, cancer, team.13 One of the initial duties is the prevented by the absence of bacterial 4hypertension, and heart disease. identification and education of poten- plaque, and the client must participate Conventional dentures typically tial implant candidates. The success of in primary preventive measures.23-28attain only limited success with respect the implant relies heavily on the health Compliant clients are ideal candidates,to both client satisfaction and chewing of the implant environment. Control of since implants are maintenance inten-ability. An implant-retained prosthesis bacterial plaque through home care has sive. Noncompliant clients need to beprovides greater stability, improved bit- been related to periimplant bone loss.14 fully educated and thoroughly traineding and chewing forces, and higher Implants should not be placed in the before implant therapy begins.29client satisfaction than a conventional client who cannot demonstrate an Behavior modification is essential indenture.5-11 Dental implants also may be effective home-care regimen.15 An these situations. The client should beused to replace teeth in a client who is implant candidate must understand and discouraged from becoming compla-partially edentulous. Osseointegration accept the time and financial commit- cent with home care and understandprovides support for function, while ment that the procedures require. The the importance of plaque control anddental implants are used as replace- dental hygienist should also be aware of tissue health. Clients that lost their teethments for natural teeth. Technological the client’s overall health history.There due to poor self-care can easily returnadvances have allowed for the increased should be minimal risk to the client to previous neglectful behaviors.30acceptance and use undergoing surgery, The maintenance appointmentof dental implants An implant-retained and the client allows the dental hygienist to partici-in a variety of res- should be free of pate in many aspects of implant treat-torative treatments. prosthesis provides any systemic illness- ment. Assessment of tissue health can The dental greater stability, es or other factors allow for early intervention in the dis-hygienist is involved that may delay heal- ease process. Although the soft tissuein all facets of client improved biting and ing.16-19 Finally, the surrounding the implant is similar tocare, the consistency chewing forces, and client must have the environment of a natural tooth, theof which leads to adequate bone in periimplant connective tissue is moreenhanced relation- higher client which to place the vulnerable to infection due toships. Combined satisfaction than a implant. An ideal decreased vascularity and lack of truewith maintenance radiographic assess- connective attachment.15,31–34 Clinicalskills, strong client/ conventional denture. ment of bone dis- assessment includes determining thecaregiver bonds allow plays quantity of presence or absence of bacterial plaque,the dental hygienist to function as a bone in three dimensions, anatomical bleeding on probing, and exudate.32,35,36vital member of the dental implant landmarks, and the quality of available Investigators are sharply divided on theteam.12 A comprehensive knowledge of bone.20 For clients with inadequate issue of periodontal probing in the2 special supplemental issue—Access
  4. 4. implant environment. It has been sug- According to Terraccino-Mortilla, Radiographs showed compact bonegested that probing of the implant sul- the dental hygienist should document formation around three tooth-shapedcus is not truly diagnostic and can be all findings.13 Documenting of baseline pieces of shell implanted in sockets ofdetrimental to the delicate attach- data is important, as changes can be an missing lower incisors, similar to thement.15,33,36,37 It also has been suggested early predictor of impending problems. bone surrounding a modern bladethat probing is indicated only in Baseline data should include the pros- implant.43implants where pathology such as thesis design, hard and soft tissue eval- Innovations in dentistry dwindledbleeding and exudate is present.32,38 uation, occlusion, radi- following the fall of theTissue health is a strong predictor of ographs, implant mobil- Roman Empire, butthe long-term success of the dental ity, and procedures per- Early Etruscans they were revived dur-implant. Assessment of the implant soft formed to maintain the replaced missing ing the Renaissance. Bytissue should be accompanied by a implant. Oral hygiene the 1800s, fixed bridgesradiographic examination of the hard status and the client’s teeth with and partial denturestissue surrounding the implant. responses and attitudes artificial teeth were successful meth-Radiographs should be evaluated for should be documented. ods of tooth replace-the presence of radiolucencies and Management of data carved from the ment. In 1885, Dr. J.M.excessive bone loss.15,32,33,36,37,39,40 can be accomplished by bones of oxen. Younger implanted a During the maintenance appoint- use of a special form natural human toothment, the dental hygienist should that follows the course into an artificial socket.remove deposits of any nature, includ- of the implant from baseline data col- Younger’s procedure included filling theing soft plaque and calculus. lection.42 Finally, the dentist should be pulp chamber of the tooth with guttaDebridement is accomplished with informed of the status of the implant so percha and the apical opening withimplant-safe instruments. Plastic, that problems can be addressed expedi- gold. A tooth from any source wasgraphite, and gold-tipped instruments tiously.13 acceptable, according to Younger, pro-can be used to remove deposits with- vided that asepsis was maintained.out damaging the implant surface Although his work was largely unsuc-(Figures 1-3). An ultrasonic tip may be History of Implants cessful, it spurred many later attemptsused only with a plastic covering that at implantation. Technical advancesprevents gouging and disturbance of The dental implant has a lengthy include implanted tubes of gold andthe titanium surface. Polishing the visi- history, beginning with ancient iridium, lead and porcelain posts, andble portion of the implant can be Egyptians, who implanted teeth in bovine incisor teeth into natural oraccomplished with rubber cups and corpses in accordance with religious artificially created sockets.43nonabrasive polishing paste or tin beliefs regarding the afterlife. Accord- In 1948, two American dentists,oxide.15,32,39-41 In the first year following ing to evidence discovered in under- Gershoff and Goldberg, surgicallyrestoration of the implant, the client ground burial chambers in what is now placed a subperiosteal implant createdshould be evaluated every three modern Italy, early Etruscans replaced by Dr. Gustav Dahl of Sweden. Themonths. The dental hygienist should missing teeth with artificial teeth subperiosteal implant was prefabricatedtake oral hygiene, tissue health, and carved from the bones of oxen. The based on a study model. This methodamount of deposits into consideration Romans conquered the Etruscans and of implantation met with limited suc-to determine a client-specific recall employed their dental techniques until cess and proved over time to have asystem after the initial 12-month peri- the fall of Rome. The earliest high failure rate due to infection.43 Inod. A four- to six-month recare system endosseous implant was discovered in a 1965, Swedish orthopedist P. I.should be used dependent on the indi- mandible fragment of Mayan origin Brånemark placed the first titaniumvidual factors.15,32 dating from about A.D. 600. implant and coined the term “osseoin-Figure 1. Plastic scaler. Figure 2. Graphite scaler. Figure 3. Gold-tipped scaler. Access—special supplemental issue 3
  5. 5. tegration.”44 Osseointegration—incor- the TMI system. TMI is more invasive The first consideration is theporation of the implant with the than other implants and usually client’s medical history.Vital signs suchbone—is one of the greatest achieve- requires hospitalization. Scientific liter- as blood pressure, pulse, and respirationments in implant dentistry. In 1967, Dr. ature indicates success with this system, should be assessed and documented toLeonard Linkow of New York City although it is very demanding for the determine if the client is capable ofplaced the first blade implant, and by client and the practitioner.49 undergoing surgery requiring anes-the 1970s, this was the most frequently Blade or plate-form implants are thetic and pain-controlling medica-employed implant design.44 also considered endosteal implants. tions. Basic lab work such as blood Blades, successfully used in a variety of count, urinalysis, or sequential multiple bone widths and heights, can be placed analyzer of the blood chemistryTypes of Implants anywhere in the mandible or maxilla (SMAC) can assist in ruling out sys- with sufficient bone.They can be placed temic complications.16,57 A subperiosteal implant is not when a client does not have adequate To be considered for implants, theplaced within alveolar bone, but under bone for a cylindrical implant and are client should be categorized as to clas-the periosteum, against the bone. This appropriate for most implant candidates. sification of presurgical risk, as set forthtype of implant is custom-made from a Blade implants have been used with suc- by the American Society ofdirect bone impression. This requires cess for the last 30 years.50,51 Anesthesiology.57,58 Class I includes thetwo surgeries—the first for fabrication Similar to the shape of a natural client with no systemic illnesses and aand the second for implant placement. tooth root, root-form implants can be normal lifestyle. Clients with well-con-The subperiosteal implant is rarely placed in the mandible or maxilla with trolled systemic illnesses who are ableindicated except for severely resorbed adequate bone. This endosteal implant to engage in normal daily activity areedentulous areas.45 Atrophic changes in can also be placed in one or two categorized as Class II. Clients in class-the edentulous jaw are common, caus- stages.45 Although root-forms require es I and II are usually considereding implant mobility and decreased sta- osseointegration achieved in a two- implant candidates. A client withbility, and facilitating infection.46 stage procedure, no impaired activitySubperiosteal implants are rarely seen significant differ- because of a chronictoday because they were commonly ences in the success To be considered for condition or mul-removed due to complications. The of one-stage or implants, the client tiple medical prob-client with the subperiosteal implant two-stage insertion lems falls into Classmust be continuously monitored and are noted in the lit- should be categorized III, and may be athe implant must be removed upon erature.52-56 The as to classification of candidate for im-infection to prevent extensive damage root-form implant plants but willto the alveolus.47,48 has been studied presurgical risk, as set require certain meas- Endosteal implants have proven more than any forth by the American ures prior to sur-successful in single-tooth replacement other implant form. gery to stabilizeas well as in the edentulous arch. One It has consistently Society of systemic problems.or two surgical interventions may be proved safe and effi- Anesthesiology. Clients in classesrequired for placement. One-stage cacious in the sup- IV and V have seri-implants are placed in a single surgery, port of prosthodon- ous medical condi-and a healing collar is placed at or tic restoration.45 tions and are not appropriate implantabove the gingiva. This eliminates a candidates.57,58second surgical procedure to expose Clients who have chronic illnessesthe implant, as completes the two-stage Client Assessment that could compromise healing shouldprocedure where the implant is com- not have implants placed. Bleeding dis-pletely submerged under the gingiva at Initial assessment of an implant orders, connective tissue disorders,insertion.45 candidate should include a thorough chronic steroid therapy, and immuno- Transosteal or transmandibular medical, dental, and psychological eval- suppression therapy can hinder healingimplant (TMI) reconstruction systems uation. To ensure success of the and therefore osseointegration. Clientsare indicated only for the severely implant, the client must be in good oral who have well-controlled diabetes haveresorbed mandible.They are an invasive and physical health. Because the shown no higher incidence in implantand technique-sensitive form of implant is maintenance intensive, the failure; however, an uncontrolled plas-endosteal implants. Bone loss is stopped implant client must also be prepared to ma glucose level can have a negativeand bone growth may be induced by maintain the health of the restoration. effect on the healing potential of the4 special supplemental issue—Access
  6. 6. implant, so that is a contraindication and/or neglect.62 The client who is alveolar canal that can affect the suit-for implant treatment.59,60 Tobacco use typically noncompliant will require ability of the implant; also, panoramichas also been statistically associated thorough education and should radiographs can adequately depictwith implant failure. The clinician demonstrate compliance and a com- bone height. Like the periapical X-ray,should address the impact smoking has mitment to home-care and mainte- it is inadequate for the examination ofon implant survival and may choose nance visits before implant therapy is bone width, but is commonlynot to place implants in smokers.61 initiated.15 employed in initial treatment planning Psychological evaluation of the The client who became fully or screening.20,64implant candidate includes intangible edentulous as a result of periodontal Digital radiography is rapidlyfactors that affect the outcome of the pathogens is at no greater risk for peri- evolving and has shown tremendousrestoration.The client must have realis- implantitis due to periodontal potential in generating images intic expectations of the restoration in pathogens. A liter- panoramic andregard to its usefulness and aesthetic ature review by periapical films.value.The practitioner should take into Quirynen et al.account the needs and desires of the indicates that, a The client who became Occlusal be used graphs can radio-implant candidate, and fully inform the month after dental fully edentulous as a only to evaluateclient how these will be met.57 The extraction, certaintypes of procedures expected, as well as known periodon- result of periodontal the mandibular sym- physis, so they arethe expected impact of transitional tal pathogens can pathogens is at no limited in theirrestorations, should be disclosed to the no longer be de- applicability. Theclient. The client also should have a tected.63 The levels greater risk for relationship of therealistic concept of the time commit- of pathogens remain periimplantitis due to maxilla, mandible,ment required. He or she should be barely detectablefully apprised that implant placement after replacement periodontal pathogens. and skullevaluation require base mayand restoration involves a number of of the teeth by in certain casesstages and need ample time for healing implant-supported such as the com-and osseointegration. prostheses. There also is a strong simi- pletely edentulous client or the client With respect to the cost of larity in subgingival plaque composi- who may require orthognathic correc-implants, the client should be aware tion in implants and teeth in the par- tion. The lateral cephalometric radi-that the financial commitment includes tially edentulous clients. A tooth with ograph may be indicated in thesepaying not only the implant place- advanced periodontitis can act as a cases.64ment, ancillary procedures, and restora- reservoir for periodontal pathogens; Computer axial tomography (CT)tion fees; but also the required ongoing therefore, partially edentulous clients enhanced with special dental process-maintenance costs. Maintenance are at greater risk for periimplanti- ing programs provides the greatestrequires three-month visits and radi- tis.41,63 This promotes the notion that a detail with panoramic, cross-sectional,ographs in the first year following good implant candidate is one who is and three dimensional views of therestoration and four- to six-month etiology-controlled and free from den- mandible or maxilla. The CT scan canrecare afterward.32,40 There also may be tal diseases.15 predict bone volume and density asa need to replace devices used to inte- Dental evaluation of the implant well as the accurate position ofgrate the implant and the prosthesis. candidate must include a thorough anatomical landmarks; however, cost,The client must have the ability to radiographic examination to allow access, and radiation exposure must bemaintain oral hygiene throughout evaluation of the alveolar bone. By weighted against the advantages beforetreatment to protect the healing considering the anatomy of the the client undergoes a CT scan.20,64implant site from pathogenic bacteria. implant site, the practitioner can deter- The oral examination should take A thorough dental evaluation mine the prescribed radiographs. A radiographic determinants into account.should be performed that includes periapical radiograph shows the loca- The client must have adequate bonequestioning the client regarding dental tion of tooth roots and opaque foreign width and height for placement andhistory. Identification of the cause of bodies that can affect the implant site. osseointegration of the implant.the client’s tooth loss is imperative.The However, it does not indicate bone Positioning of the implant is key andclient who lost teeth as the result of width and so is limited in this indica- the partially edentulous client musttrauma or an accident will likely be tion. Panoramic radiographs can be have adequate spacing.The client’s gin-more compliant in home-care than the used to locate anatomical landmarks gival tissues should be examined forclient who lost teeth due to disease such as the maxillary sinus or inferior adequacy and health.57 Access—special supplemental issue 5
  7. 7. Treatment Planning the restoration. Fees and methods of payment should be reviewed and Joint treatment planning for agreed upon beforehand, and a written implant procedures can begin when consent should be signed by the client oral health is achieved; home care is for both surgical and restorative treat- effective; and the client is fully educat- ment.57 ed as to costs, implications, and treat- ment options.The key to success in thisFigure 4. Soft bristle brush. stage is effective communication Surgical Placement of between the involved parties. The the Implant restorative dentist should have a con- ference with the surgeon who will be Throughout all phases of implant placing the implants. Specialists who treatment, the dental hygienist func- may be providing ancillary treatment, tions in the primary prevention of dis- the dental hygienist, and the laboratory ease at the implant site. The dental technician also may be included. hygienist must make home-care modi- Considerations for the dental team fications and provide reinforcement to should include the client’s medical, the client at each stage. Following the dental, and psychological status. initial placement of the implant or the Providers delivering preliminary treat- first stage of treatment, the client mustFigure 5. Example of a power toothbrush with ment such as periodontal therapy, be advised of the need for gentle butmultiple brush tips that allows complete access extractions, or orthodontics can inform thorough home care. Sutures and clientaround an abutment. the dental team of client progress. avoidance of the surgical site should be Throughout early treatment or team addressed as mismanagement of them discussions, the client’s unsuitability as a can lead to retention of plaque at the candidate for implant treatment may be implant site.13 Vertical crestal bone discovered. At this point, alternate defects have been noted in one-stage treatment plans including fixed bridge- surgery in the absence of plaque control work and partial or complete dentures in this initial healing period.15,65 The should be presented to the client.57 client should be instructed to rinse with The implant team should be chlorhexidine gluconate or apply it mindful of the client’s needs and desires with a swab or tufted brush twice daily. and work in cooperation to provide The substantivity of chlorhexidine optimal restoration.The restoring den- combined with its antibacterial proper-Figure 6.Yarn. tist should create a definitive treatment ties can assist in plaque control.15,66 plan for the client.A diagnostic wax-up This gentle debridement is effec- should be made in anticipation of the tive only in the initial healing phase final restoration. This will allow the and a new home care regimen should dentist to consider spatial relationships be introduced subsequently to include and the alignment of the implants in a soft toothbrush. Single-tooth restora- the context of the existing teeth. tions can be managed with a soft Working with the surgeon to fabricate toothbrush and floss. Clients who have a surgical template, the dentist can help provisional restorations also should be achieve proper alignment and place- instructed in home care. Several ment of the implant.57 devices can facilitate access to a fixedFigure 7.Tufted floss. The client should be fully aware of restoration, including an interdental how treatment will proceed. His or her brush, end-tuft brush, or an interprox- Hard-tissue and soft-tissue assessment obligation to maintenance of the imal oral health aid. Superfloss or flossshould include mounted study casts.The implant, including home care and den- threaders also can remove plaque fromclient may require preliminary treat- tal visits, should be outlined.The prac- abutment areas. The client shouldment, such as periodontic, orthodontic, titioner should discuss possible compli- know where the abutments are andor restorative treatment, to obtain dental cations and the client should have real- how to use oral hygiene aids to cleanhealth or facilitate implant therapy.57 istic expectations of the outcome of them.13,15,676 special supplemental issue—Access
  8. 8. At stage-two surgery, the implant when embrasure space permits (Figureis exposed and a healing cuff is placed 8).The wire center of the brush shouldto promote tissue maturity. The client be coated with plastic or nylon to pre-should rinse with chlorhexidine twice vent scratching of the implant surface.daily in the 14 days following exposure An end-tuft brush can access smallerof the implant, and then implement spaces and be manipulated under hotmechanical debridement with a soft water to accommodate the shape of thetoothbrush or other aid. Chlorhexidine prosthesis (Figure 9). Foam tips, inter- Figure 8. Interdental brush for maintenance ofshould still be used once a day and proximal brushes, and disposable implant-based fixed prosthesis.should be applied with the same aid wooden picks are among the manyused for mechanical debridement.15 auxiliary devices that can assist in plaque removal. Chlorhexidine or anti- septic rinses can be delivered withRestoration of the these interdental aids to enhance theirImplant effectiveness.68 Plaque control in a single-tooth When the tissue has adequately replacement is relatively simple. Thematured and the final restoration is implant abutment is easy to access withdelivered, the dental hygienist should a toothbrush and the client should beagain modify and reinforce home-care taught to clean the subgingival portionprinciples, considering access to the of the abutment. Chlorhexidine orimplant, client dexterity, and design of antiseptic rinses should be delivered by Figure 9. End-tuft brush.the final restoration. floss daily.Auxiliary aids can be used by A soft sulcular toothbrush is the clients who are unable to floss or haveprimary plaque-control device for the posterior restorations that are difficultimplant abutment (Figure 4). A client to maintain.68 Adequate oral hygiene iswith limited dexterity should use a required for all natural teeth to main-power or sonic toothbrush. Certain tain health and prevent the emergencepower toothbrushes with multiple of periodontal pathogens that can rap-brush tips allow complete access idly destroy delicate periimplant tis-around an abutment (Figure 5). Sonic sue.13,30,48,67 Figure 10. Calculus buildup around a fixedand other powered brushes are also safe A prosthesis that is fixed to the bridge retained by and implant.to use around the titanium abut- implants and is not removed by thement.13,15,67,68 client requires a more detailed home- hygiene routine to remove materials Dental floss can be used to deliver care regimen. Access to the implants is that were loosened but not dislodged.68chlorhexidine to the implant on a daily often limited by esthetic demands.The Clients who are able to removebasis.The use of four-essential-oil rins- dental hygienist should develop a their prosthesis have access to thees twice daily also has been shown to maintenance plan for the client that implant abutment, and they may retainprovide benefit to the implant client.69 effectively removes plaque from proxi- the denture with a bar or a ball attach-Floss should be inserted at the buccal mal surfaces. Powered toothbrushes, ment. It is imperative that these pros-surface of the implant, threaded around floss with threaders, and interdental thetic attachments, as well as thethe lingual aspect, and crossed back to aids can all be used with fixed-implant implant abutments, be cleaned as a partthe buccal to completely surround the prostheses.The delivery of chemother- of the oral hygiene program.abutment.67 Gauze strips, yarn, or apeutics such as chlorhexidine or anti- Mineralized deposits can build up verythicker dental floss or dental tape can septic rinses is especially important quickly and interfere with the seatingassist with plaque control in wide because of the decreased access. If of the denture (Figure 10). A nylonembrasures (Figures 6 and 7).13,67 brushing or flossing in the lingual flossing cord is abrasive enough to A client who is not able to use aspect is limited, an oral irrigation remove calculus and is indicated for thefloss can be instructed in the use of the device can be used on a low setting. abutment surface, ball attachment, andinterdental aids. The clinician should The irrigant should be directed ridge bar.The bar and ball attachmentsconsider the embrasure size and shape through the contacts rather than into also can be cleaned with a soft-bristlein the selection of the interdental aid. the tissue. Irrigation should be per- brush, end-tuft brush, or interproximalAn interproximal brush is indicated formed at the completion of the oral brush. Dental floss, superfloss, gauze, or Access—special supplemental issue 7
  9. 9. yarn dipped in chlorhexidine or anti- parallel to the implant surface without Because the attachment of theseptic rinse should be used around the true attachment. It also is less vascular implant is different from that of a nat-implant abutment. All surfaces of the and has fewer fibroblasts than in the ural tooth, the implant is easily com-prosthesis must be cleaned with a stiff gingival structures around teeth.32 This promised by stress. An occlusal evalua- 13,29,30nylon denture brush daily. connective tissue attachment forms a tion is required to assure that there are During each visit, the dental barrier that protects the implant from no excessive or traumatic stresses onhygienist should assess the client’s oral bacteria and occlusal forces.The delica- the implant. Improper contacts, brux-hygiene and make necessary modifica- cy of this barrier should be kept in ism, or other occlusal discrepanciestions. Home care should be reviewed mind when probing or scaling the must be remedied to prevent bone loss.and reinforced with written instruc- implant sulcus. The prosthesis should have adequatetion.67 While there contacts and embrasure spaces to facil-is no single oral itate home care.13hygiene aid that Brushing should be Baseline It has been clearly established thatcompletely removes the periimplant tissue is susceptible toplaque, the clinician the primary aspect of Data bacterial accumulation and subsequentshould keep in the oral hygiene Immediately fol- infection. Soft-tissue examination atmind that compli- lowing delivery of baseline allows for comparison of peri-ance is dependent program. To the final restoration, implant health at subsequent examina-on the simplicity of maximize the dental hygienist tions. The benefit of probing thethe procedure, theamount of time it compliance, only one should thoroughly document baseline implant sulcus is a debatable topic, dependent on the investigator. The cli-requires, and a min- auxiliary aid should data. Deviations from nician should exercise personal judg-imal number of oralhygiene devices. be used, if possible. this an earlydata can be initial indica- ment when deciding whether or not to probe apparently healthy tissue. InBrushing should be tor of problems in observing signs of infection, the clini-the primary aspect of the oral hygiene the dental implant. The dental hygien- cian should probe the periimplant tis-program. To maximize compliance, ist should begin by noting the prosthe- sue.32,38 Probing should be accomplishedonly one auxiliary aid should be used, sis design. It also can be helpful to note with a plastic periodontal probe (Figureif possible.30 any inherent problems in the design 11). Ideal pocket depths are under 4 mm that can affect plaque removal. An and there should be no bleeding. Color, account of the types of implants and consistency, and presence or absence ofMucogingival Tissues their locations also should be recorded.13 edema should be assessed by visual Poor surgical technique, traumatic examination. Slight pressure on the soft Because of osseointegration, the occlusion, or inadequacies in the pros- tissue can produce bleeding, exudate, orimplant can function as a natural tooth. thesis can all cause bone loss.This bone tenderness in inflamed periimplant tis-However, it is unlike a natural tooth in loss results in a reservoir for bacterial sue. The clinician also should measureits susceptibility to disease and the colonization and further breakdown of recession.13 The absence of keratinizedrapid destruction of the surrounding the periimplant tissues.70 The hard-tis- tissue has not conclusively been showntissues. Although the soft tissue of the sue evaluation should include radi- to predispose implant tissue to disease;tooth and implant resemble each other, ographs, evaluation of occlusion, and however, the presence of keratinized tis-there are inherent differences in the examination of the prosthesis. Radio- sue surrounding the implant can makeconnective tissues. The periodontium graphs should be taken to monitor oral hygiene procedures easier toof a natural tooth consists of alveolar bone levels around the implant and accomplish.71bone, periodontal ligament, cemen- evaluate the health of the bone.A peri- The dental hygienist should keep atum, and the gingiva. The implant is apical X ray with correct density and record of the client’s home-care proce-surrounded by periimplant tissues and angulation, taken with a paralleling dures including recommended aids andlacks a periodontal ligament. The sur- technique, can display marginal bone chemotherapeutics.The client’s respons-face of the a tooth has a connective tis- loss and components of the prosthesis.15 es and attitudes toward the home-caresue attachment with collagen fibers The dental hygienist should document procedures should be noted as well.inserted into the cementum. The con- the radiographic technique and repeat This will allow assessment of the suc-nective tissue in the implant is com- it at future examinations to promote an cess or limitations of this regimen inpromised because collagen fibers run accurate comparison.13 the future (Figure 12).138 special supplemental issue—Access
  10. 10. Maintenance or occlusal stress on the implant. All surfaces of the prosthesis should be free In the first year following restora- of scratches, fissures, and gouges thattion of the implant, frequent recalls are can harbor bacterial plaque.13needed. The client should be assessed The evaluation of the health of theevery three months. Recall for the periimplant tissue should include clini-implant client after those initial 12 cal inspection for signs of inflammation.months should be dictated by the The dental hygienist should also noteclient’s individual needs. These factors the nature of deposits on the implant Figure 11. Use of the plastic probe.include stability of the implant tissues, abutment. The presence or absence ofperiodontal health of the surrounding debris, plaque, and supragingival or sub-teeth, systemic health, and the effec- gingival calculus should be noted andtiveness of home-care procedures.32 further quantified as light, moderate, or Maintenance visits include periim- heavy.13plant evaluations, prosthetic evalua- Removal of deposits should betions, deposit removal, home-care rein- accomplished only with instrumentsforcement and modifications, and radi- that are incapable of damaging theographs when indicated. A comparison implant surface. A variety of instru-of findings to baseline data can indicate ments similar to curets and scalers areimpending problems with the available in plastic, nylon, or graphite.implant.13 Gold-tipped instruments can be used In the first year of treatment, radi- but must be examined before use for Figure 12. Measuring the keratinized gingiva.ographs of the implant should be taken exposure of the underlying metal and The metal probe should never be used to probeat each three-month recare visit. After should never be sharpened.32 If a client around the implant.that, an annual radiograph should be is performing an effective home-caretaken and compared to the baseline regimen, subgingival calculus should ment, the metal instruments must beradiograph. Because of surgical trauma, be light. Calculus is not firmly attached covered with plastic tips.13,32,67 The air-it is reasonable to ex- to the implant because powered abrasive unit is contraindicatedpect 1.5 mm of bone of the nonporous tita- by some investigators.A review of sever-loss in the first year and In the first year of nium surface and al studies examining several types of0.2 mm each year treatment, should be easily remo- instruments and their effects on thethereafter.32,40 Exces- vable. The dental hy- implant surfaces reveals the air-abrasivesive bone loss must be radiographs of the gienist should scale unit to be safe and effective in removingaddressed immediately. implant should be with short working deposits.72-75 A rubber cup can be used to Implant mobility strokes and light pres- polish the implant surface with acan be a sign of signif- taken at each sure to prevent trauma nonabrasive paste or tin oxide.15,32,67icant problems. Stabi- three-month to the delicate periim- As home-care factors greatly intolity of the implant plant sulcus. Upon health of the implant, the dental hygien-should be assessed at recare visit. insertion of the instru- ist should motivate the client to continueeach recare appoint- ment, the blade should the regimen. If home care has not beenment.Mobility can occur at the abutment- be closed against the abutment and effective, the dental hygienist shouldprostheses connection and requires then opened past the deposit. The question the client and attempt torepair.13 Mobility of the implant body deposit should be engaged apically resolve those issues. If the employed aux-is more serious, as it implies a loss of with the stroke extending coronally. A iliary aids are not effective, it may beintegration.15 horizontal, oblique, or vertical stroke necessary to modify or change the client’s The prosthesis and attachments should be used, depending on the loca- techniques or change the type of aid.should be examined for adequacy and tion of the deposit.13 The dentist should be immediate-continued function. Mechanical diffi- Prostheses can sometimes limit ly be informed of any problems orculties in the prosthesis, such as a frac- access of the scaler, and an ultrasonic or concerns. Changes in implant healthture, can cause excessive occlusal stress sonic scaler can facilitate removal of must be addressed immediately, asand contribute to periimplant bone deposits.When using the sonic or ultra- should problems related to occlusion,loss.40 There should be no undue force sonic device to scale the implant abut- prosthetics, and mobility.13 Access—special supplemental issue 9
  11. 11. Periimplant mucositis is similar to Summary gingivitis around a tooth in its bacteri- al etiology and its reversibility. This Although the dental implant bacterial infection is marked by inflam- requires constant maintenance and matory changes with bleeding on monitoring, it can be a predictable probing, edema, and tenderness. Its replacement for natural teeth. Studies unchecked progression can lead to have shown that implants can be supe- periimplantitis, which affects the sur- rior to removable prosthodontics in rounding bone. Increased pocket aesthetics, stability, and chewing forces.Figure 13. Radiograoph of a treated “ailing” depth, presence of exudate, and bone From education to assessment, the den-implant. loss accompany the inflammation in tal hygienist is a constant in a dynamic the periimplant soft tissue (Figures 13 process. The capacity of the dental and 14).15,32,33 hygienist to function within the The ailing implant demonstrates implant team is a great benefit to the radiographic bone loss without clinical potential and current implant candi- inflammation.The pocket depth can be date. advanced but is marked by the absence of bleeding. The inflammatory process may have been arrested or bone loss could have resulted from trauma. There is no The ailing implant must treatment forFigure 14. Radiograph of an “ailing” implant. be monitored closely at each maintenance visit.38 the failed The failing implant implant and it presents with consistent deterioration at mainte- must be nance intervals (Figure removed. 15). Inflammation is pres- ent and observable with signs of bleed- ing, edema, redness, and exudate.There is no mobility, but radiographic boneFigure 15. A failing implant with purulent loss is detectable. Intervention for theexudate. failing implant can be successful. Treatments include detoxification of the implant surface and surgical inter- ventions. The source of the problemAiling/Failing Implants must be identified and eliminated.38 Implant failure is multifactorial The biological reaction of the and the cause may be unidentifiable.implant to pathogenic bacteria can The progression of inflammation andhave an impact in the long-term suc- traumatic forces can result in destruc-cess of the implant. It is for this reason tion of the bone. The failed implantthat thorough examination of the presents with clinical inflammation,implant structures at maintenance visits radiographic bone loss, and clinicalis indicated. Changes in implant health mobility. There is no treatment for thecan indicate if the implant is ailing or failed implant and it must befailing, or has failed.38 removed.3810 special supplemental issue—Access
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