Test 75.2
before, during, and after
implant placement. For
example, interproximal brush-
es can penetrate up to 3 mm
into a gingival...

Oral Hygiene...   ...

Oral Hygiene...        ...

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  1. 1. 70 Test 75.2 IMPLANTS Oral Hygiene and Maintenance of Dental Implants L ong-term predictability of dental implants and their associated restora- tions has been demonstrated.1-3 As the number of patients treated with dental implants continues to grow, dentists must accept the challenges of maintaining these sometimes complex restorations. Proper monitoring and maintenance is Lee H. essential to ensure the longevity of the dental Silverstein, DDS, implant and its associated restoration MS through a combination of appropriate profes- sional care, evaluation, and effective patient oral hygiene.4,5 The value of using conven- tional periodontal parameters to assess peri- Figure 1. Comparison of crestal gingival fiber orientation. implant health has not been completely defined.4 Therefore, it is important that clini- cians understand the similarities and distinc- tions between the dental implant and the nat- ural tooth. Subsequently, by examining the Gregori M. Kurtzman, DDS similarities and differences between a natural tooth and a dental implant, basic guidelines can be provided for maintaining the long- In more recent years, implant maintenance and effective patient home care have been Figure 2. Microscopic comparison of gingival fiber orien- emphasized as two critical factors needed for tation (natural tooth on left, implant on right). Figure 3. Gingival fibers between 2 natural teeth showing orientation perpendicular to the long axis of the teeth. long-term success of dental implants. term health of dental implants. Direct anchorage of an implant to alveolar bone provides a foundation to support a den- tal prosthesis and transmits occlusal forces to the alveolar bone. This is the definition of osseointegration.6 Recently, the focus of implant dentistry has expanded from obtain- ing osseointegration, which is highly pre- dictable, to include the long-term mainte- nance of health of the peri-implant hard and soft tissues. This can be achieved through appropriate professional care and patient cooperation via effective home care.7 Patients must accept the responsibility for implant maintenance, therefore the patient selection process should take into account the patient’s Figure 4. Gingival fibers between 2 implants showing orientation parallel with willingness to maintain the fixture and the long axis of the implants. restoration. Diagnosis and treatment plan- ning based on a risk-benefit analysis should be performed subsequent to a thorough med- There is evidence that bacterial plaque must begin at the time of dental implant ical, dental, head-and-neck, psychological, not only leads to gingivitis and periodontitis,9 placement and should include the use of vari- temporomandibular joint, and radiographic but also can induce the development of peri- ous adjunctive aids to clean the altered mor- examination.8 implantitis.10 Thus, personal oral hygiene phology of the peri-implant region effectively DENTISTRY TODAY • MARCH 2006
  2. 2. before, during, and after implant placement. For example, interproximal brush- es can penetrate up to 3 mm into a gingival sulcus or pocket and may effectively clean the peri-implant sul- cus.11 In addition to mechan- ical plaque control, daily rinses using 0.1% chlorhexi- dine gluconate or Listerine (Pfizer)12 may provide addi- tional benefits. Effective oral hygiene around dental implants can be challenging to achieve over the long term, and the patient, dentist, and dental hygienist must exercise con- siderable effort to achieve the desired results. During the maintenance visit, the dental professional should concen- trate on the peri-implant tissue margin, implant body, prosthetic abutment-to-im- plant collar connection, and the prosthesis.13 Clinical in- spection for signs of inflam- mation (ie, bleeding on prob- ing), exudate, mobility, and increased sulcus depth, and a radiographic evaluation of the peri-implant area still consult pro remain the standard ap- proach to evaluating the sta- tus of endosseous dental im- plants. For example, success- ful and stable endosseous dental implants exhibit no mobility. But, if clinically per- ceptible mobility is detected, then subsequent to radi- ographic evaluation of the implant and its bony hous- ing, the abutment retaining screw 14 and/or prosthetic abutment-collar interface should be examined for loose- ness or breakage. Therefore, different types of clinical assessment are used routinely, except for periodontal probing around peri-implant tissues that appear to be in a state of good health. The baseline data and data from subsequent maintenance visits should be recorded in the patient’s chart to properly assess the peri-implant status over time. Subsequent to a thor- ough intraoral examination, unless there is visual evi- dence of soft-tissue changes (ie, inflammation of peri- implant tissue with even slight attachment loss or mucositis), routine probing of the peri-implant tissue should not be performed.15 continued on page 72 FREEinfo, circle 48 on card
  3. 3. 72 IMPLANTS Oral Hygiene... Usually during the first year tip advances, passing between absence of keratinized tissue continued from page 71 after the implant is restored, the fibers of the gingival cuff in this critical area has not a 3-month maintenance sched- until the crestal bone prevents been unequivocally docu- ule should be implemented, it from advancing. mented to indicate that peri- especially if the patient has The peri-implant mucosal implant tissues are more vul- lost teeth because of peri- seal may be a less effective nerable to the ingress of path- odontal disease. However, if barrier to bacterial plaque ogenic bacteria. However, the after 12 months the patient’s than the periodontal attach- ability of the patient to main- implants are stable and peri- ment around a natural tooth.20 tain good home care around implant tissues are healthy, There is less vasculature in dental implants is facilitated then a 4- to 6-month mainte- the gingival tissue surround- by the presence of keratinized nance regimen can be imple- ing dental implants compared tissue surrounding them. mented.16 The clinician must to natural teeth. This reduced Thus, if a patient has no ker- be cognizant of each patient’s vascularity, concomitant with atinized tissue around an im- level of home care effective- parallel orientation of the col- plant, and a pull from a frenum Figure 5. Plastic curettes for scaling dental implants and demonstration of the ness, systemic health, and lagen fibers adjacent to the or a chronic peri-implant implant surface after use. Note that there is no alteration to the surface. status of the peri-implant tis- body of the implant, makes mucositis exists, then place- sues when determining these dental implants more vulnera- ment of a soft-tissue autoge- intervals. ble to bacterial insult.21 nous or allogeneic connective With dental implant During maintenance ap- tissue graft is recommended patients, the dental profes- pointments, peri-implant perio- to facilitate proper mechani- sional must evaluate the dontal probing should be per- cal oral hygiene.26 prosthetic components for formed only where signs of Specific clinical criteria as- plaque, calculus, and the sta- infection are present (ie, exu- sociated with dental implants bility of the implant abut- date, swelling, bleeding on that should be monitored for ment. Radiographs of dental probing, inflamed peri-implant an indication of early implant implants should be taken soft tissue, and/or radi- failure have not been clearly every 12 to 18 months during ographic evidence of peri- defined. Currently, the pres- these maintenance visits.17 implant bone loss). Lastly, ence of fixture mobility is the For dental implant restora- routine periodontal probing of best indicator of implant fail- tions that are screw-retained, dental implants should not be ure.27 Differing from natural the clinician should remove performed, because this pro- teeth, healthy dental im- the prosthesis at least once a cedure could damage the plants exhibit no mobility Figure 6. Plastic scaler used for recall maintenance. year to more easily assess the weak epithelial attachment because of the absence of a status of the peri-implant around the implant, possi- periodontal ligament. There- hard and soft tissues, the bly creating a pathway for fore, healthy implants should existence of mobility of the the ingress of periodontal appear nonmobile even in the prosthetic components or the pathogens.22 presence of peri-implant bone implant fixture itself, and the Commerically available loss, if an adequate amount of patient’s level of home care.18 plastic probes should be used supporting alveolar bone still The presence of any signs of when investigating the exists.28 infection, radiographic evi- crevicular depth around den- When monitoring the dence of peri-implant bone tal implants. The probing health of the peri-implant loss, and/or neuropathy may depth around dental implants soft tissues, the practitioner be indicative of an ailing or may be related closely to the should be looking for changes Figure 7. Alteration of implant surface after use of stainless steel scalers. failing implant.19 thickness and type of mucosa in soft-tissue color, contour, surrounding the implant. A and consistency. The presence IMPLANTS VERSUS healthy peri-implant sulcus of a fistulous tract is a serious NATURAL TEETH has been reported to range clinical sign and could indicate It is essential that the clini- from 1.3 to 3.8 mm, which is the presence of serious patholo- cian understands the rela- greater than the depths gy or implant fracture.29 tionship between the gingiva reported for natural teeth.23 and the structure it attaches The best indicator for evalu- BLEEDING ON PROBING to, be it a natural tooth or an ating an unhealthy site would There is controversy in the implant. (Figures 1 and 2) be probing data gathered lon- literature as to the accuracy The fiber orientation of the gitudinally.24 and significance of bleeding gingival cuff around a natural For all of these reasons, on probing around dental tooth attaches perpendicular personal home care and con- implants.30 Presently, the lit- Figure 8. Demonstration of gouging of the implant surface that may occur to the long axis of the tooth sistent professional mainte- erature suggests that detec- following use of an ultrasonic scaler. (Figure 3). This acts as a bar- nance have proven to be criti- tion of bleeding on probing rier when a periodontal probe cal to the success and longevi- can be used as an early indi- is inserted into the sulcus. ty of endosseous dental cator of peri-implant disease The probe tip advances api- implants. This is especially or concurrently with other cally until the tip contacts true in an environment with signs of implant failure, ie, bone these fibers. adjacent natural teeth, which loss. However, as previously This orientation is not if affected by periodontal dis- mentioned, routine probing is observed around implants. ease could act as a reservoir not recommended.31 With an implant, the gingival for pathogenic bacteria and fiber orientation is parallel to seed the peri-implant sulcus.25 RADIOGRAPHIC the long axis of the implant The physical character- EVALUATION (Figure 4). When a periodontal istics of the peri-implant soft Radiographic assessment is Figure 9. Demonstration of alteration of the implant surface following applica- probe is inserted into the sulcus tissues should be the focus of one of the most useful means tion of an air polisher and baking soda. Note the change in surface texture. around an implant, the probe oral hygiene instruction. The of evaluating the status of an DENTISTRY TODAY • MARCH 2006
  4. 4. 73 IMPLANTS XXX endosseous dental implant. nicians suggest the use of a for implants (Figure 9). Even connection with the coronal or a gauze strip with tin oxide. Invasion of biologic width, sonic instrument with a plas- the use of baking soda powder portion of the implant, lead- Not only is the hygiene predictable remodeling, or so- tic sleeve over the tip for scal- in these units may strip the ing to emphysema.41 Titani- armamentarium important, called “saucerization” is asso- ing dental implants.40 Air surface coating from the um or titanium alloy surfaces but so are the home care tech- ciated with an average mar- powder polishing units may implant. Additionally, the air of dental implants can be pol- niques used to maintain endos- ginal bone loss of 1.5 mm dur- also damage the implant sur- pressure from these units ished using a rubber cup with seous dental implants. Pa- ing the first year following face and should not be used may detach the soft-tissue a nonabrasive polishing paste continued on page 74 prosthetic rehabilitation.32, 33 This is followed by an average of 0.2 mm of vertical bone loss in each subsequent year.34, 35 Thus, progressive bone loss around a dental implant that exceeds these averages may be indicative of an ailing or failing implant. Lastly, during radiographic evaluation, no evidence of a peri-implant radiolucency (a radiolucent area between the implant and surrounding bone) should be found, because such a rar- efaction usually indicates infection or failure to osseoin- tegrate.36 PROFESSIONAL CLEANING INSTRUMENTATION Instruments made of metal, such as stainless steel, should not be used to probe or scale dental implants. The reason is that the metal can scratch or contaminate the implant surface, or cause a galvanic reaction at the implant-abut- ment interface.37 Hand scalers for cleaning dental implants can be plas- tic, Teflon, gold-plated, or made of wood (Figures 5 and 6).38 When using gold-plated curettes, the manufacturer recommends not sharpening these instruments, as the gold surface could be chipped, astra tech exposing the harder metal underneath the coating. Stain- less steel scaling instruments may abraid the implant sur- face, stripping off any surface coatings such as hydroxyap- atite (HA), as the instru- ment’s hardness is greater than the titanium alloy from which the implant is fabricat- ed (Figure 7). Other commonly used devices and materials con- traindicated for use with den- tal implants are sonic and ultrasonic scaling units, air powder abrasive units, and flour or pumice for polish- ing.39 Ultrasonic, piezo-elec- tric, or sonic scaler tips may mar the implant’s surface, leading to microroughness and plaque accumulation. The stainless steel tip may also lead to gouging of the implant’s polished collar (Figure 8). However, some cli- FREEinfo, circle 49 on card
  5. 5. 74 IMPLANTS Oral Hygiene... tients should be taught the As with natural dentition, lavage during ultrasonic in- continued from page 73 modified bass technique of adjunctive cleaning aids such strumentation or adminis- brushing using a medium-sized as flossing are still valuable. An tered by subgingival irriga- head, soft-bristled toothbrush. implant patient’s home care tion following scaling and Patients should be instructed regimen should be individually root planing have demon- in the proper use of interdental tailored according to each pa- strated minimal clinical ben- brushes. The plastic-coated wire tient’s needs. These needs are efit, with microbiota re- brush is the only type of inter- based on the location and angu- bounding to levels found with dental brush to be used with lation of the dental implants, scaling and root planing thera- dental implants, since these the position and length of trans- py alone.42,43 However, oral brushes will not scratch the mucosal abutments, the type of rinses with antimicrobial prop- implant surface (Figure 10). prosthesis, the dexterity of the erties, such as Listerine or Recently, automated or patient, and the rate of plaque chlorhexidine, have been advo- electric toothbrushes have and calculus accumulation. cated for use in patients with been advocated for daily Another popular catego- implants.44-46 home care. These devices may ry of cleansing device is the be rotary, circular, or sonic in oral irrigator, used with or SUMMARY design. The key to their effec- without an antimicrobial so- When dental implants were tiveness is proper instruction lution. Studies have sug- first introduced, the emphasis Figure 10. Plastic-coated interproximal brush applied around implant abut- in their use, and then diligent gested that the addition of for long-term success was on ments and under the superstructure for plaque removal. daily use by the patient. certain antimicrobials to the the surgical phase of treat- ment. Subsequently, the emphasis changed from a focus on the surgical tech- nique to proper fixture place- ment, which would be dictat- ed by the prosthetic and aes- thetic needs of each patient. In more recent years, implant maintenance and effective patient home care have been emphasized as two critical factors needed for long-term success of dental implants. Acknowledgment The authors would like to thank Dr. Emma Galvan for her editorial assistance with this article. metalift References 1. Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the eden- tulous jaw. Int J Oral Surg. 1981;10:387-416. 2. Cox JF, Zarb GA. The longitudinal clin- ical efficacy of osseointegrated dental implants: a 3-year report. Int J Oral Maxillofac Implants. 1987;2:91-100. 3. Albrektsson T, Branemark PI, Hansson HA, et al. Osseointegrated titanium implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. Acta Orthop Scand. 1981;52:155. 4. Orton GS, Steele DL, Wolinsky LE. Dental professional’s role in monitoring and maintenance of tissue-integrated prostheses. Int J Oral Maxillofac Implants. 1989;4:305-310. 5. Bauman GR, Mills M, Rapley JW, et al. Clinical parameters of evaluation dur- ing implant maintenance. Int J Oral Maxillofac Implants. 1992;7:220-227. 6. Rateitschak KH, Wolf HF, Spiekermann H, et al, eds. Color Atlas of Dental Medicine - Implantology. Stuttgart, NY: Thieme Publishing Group; 1995:305-316. 7. Meffert RM, Langer B, Fritz ME. Dental implants: a review. J Periodontol. 1992;63:859-870. 8. Meffert RM. Treating the Ailing Implant. In: Misch CE, ed. Contemporary Implant Dentistry. St Louis, Mo: Mosby Year Book; 1993:chap 33. 9. Warrer K, Buser D, Lang NP, et al. Plaque-induced peri-implantitis in the presence or absence of keratinized mucosa: an experimental study in monkeys. Clin Oral Implants Res. 1995;6:131-138. 10. Lang NP, Karring T. Proceedings of the 1st European Workshop on Periodontology. Chicago, Ill: FREEinfo, circle 50 on card
  6. 6. 75 IMPLANTS Quintessence; 1994. treatment plans, surgical approach, 11. Balshi TJ. Hygiene maintenance pro- healing, and progressive bone load- Continuing Education cedures for patients treated with the ing. Int J Oral Implantol. 1990;6:23-31. tissue integrated prothesis (osseointe- 36. Apse P, Ellen RP, Overall CM, et al. gration). Quintessence Int. Microbiota and crevicular fluid collage- 1986;17:95-102. nase activity in the osseointegrated 12. Ciancio SG, Lauciello C, Shibly O, et dental implant sulcus: a comparison of al. The effect of an antiseptic mouthrinse on implant maintenance: plaque and peri-implant gingival tis- sues. J Periodontol. 1995;66:962-965. sites in edentulous and partially eden- tulous patients. J Periodontal Res. 1989;24:96-105. 37. Speelman JA, Collaert B, Klinge B. Test No. 75.2 13. Garg AK. Practical Implant Dentistry. Evaluation of different methods to Dallas, Tex: Taylor Publishing Co: clean titanium abutments. A scanning 1995:111-115. electron microscopic study. Clin Oral 14. Lekholm U, Ericsson I, Adell R, et al. Implants Res. 1992;3:120-127. T The condition of the soft tissues at 38. Gantes BG, Nilveus R. The effects of o submit Continuing Education answers, use the answer sheet on page xx. On tooth and fixture abutments support- different hygiene instruments on titani- the answer sheet, identify the article (this one is Test 75.2), place an X in the box ing fixed bridges: a microbiological um surfaces: SEM observations. Int J and histological study. J Clin Periodontics Restorative Dent. corresponding to the answer you believe is correct, detach the answer sheet Periodontol. 1986;13:558-562. 1991;11:225-239. from the magazine, and mail to Dentistry Today Department of Continuing 15. Lang NP, Nyman SR. Supportive 39. Rapley JW, Swan RH, Hallmon WW, et maintenance care for patients with al. The surface characteristics pro- Education. implants and advanced restorative duced by various oral hygiene instru- therapy. Periodontol 2000. ments and materials on titanium 1994;4:119-126. implant abutments. Int J Oral The following 8 questions were derived from the article Oral Hygiene and 16. Consensus report. Implant therapy II. Maxillofac Implants. 1990;5:47-52. Maintenance of Dental Implants by Lee H. Silverstein, DDS, MS, and Gregori M. Ann Periodontol. 1996;1:816-820. 40. Gantes BG, Nilveus R. The effects of 17. Baumgarten HS, Chiche GJ. different hygiene instruments on titani- Kurtzman, DDS, on pages 70 through 75. Diagnosis and evaluation of complica- um surfaces: SEM observations. Int J tions and failures associated with Periodontics Restorative Dent. osseointegrated implants. Compend 1991;11:225-239. Contin Educ Dent. 1995;16:814-822. 41. Meffert RM. Treatment of failing dental Learning Objectives 18. Meffert RM. In the spotlight: implantol- implants. Curr Opin Dent. 1992;2:109- ogy and the dental hygienist’s role. J 114. Practical 1995;September:12-14. Hygiene. 42. Reynolds MA, Lavigne CK, Minah GE, et al. Clinical effects of simultaneous After reading this article, the individual will learn: 19. Meffert RM. How to treat ailing and ultrasonic scaling and subgingival irri- failing implants. Implant Dent. gation with chlorhexidine. Mediating • the importance of professional and home hygiene care for dental implant patients, and 1992;1:25-33. influence of periodontal probing depth. 20. Weyant RJ. Characteristics associated J Clin Periodontol. 1992;19:595-600. • professional and home hygiene care techniques for dental implant patients. with the loss and peri-implant tissue 43. Silverstein LH, Schuster GS, Garnick health of endosseous dental implants. JJ, et al. Bacterial penetration of gingi- Int J Oral Maxillofac Implants. va in the adult beagle dog with peri- 1994;9:95-102. odontitis. J Periodontol. 1990;61:35- 1 Routine probing of implants ______. 5 A stainless steel scaler may ______. 21. Nevins M, Langer B. The successful 41. a. is not recommended in the absence of a. remove surface treatment (ie, HA) from use of osseointegrated implants for 44. Mombelli A, Lang NP. Antimicrobial the implant surface the treatment of the recalcitrant peri- treatment of peri-implant infections. the signs of inflammation or implant odontal patient. J Periodontol. Clin Oral Implants Res. 1992;3:162- mobility b. scratch the titanium surface 1995;66:150-157. 168. b. should be performed at each recall c. assist in removing calculus from the sul- 22. Lang NP, Wetzel AC, Stich H, et al. 45. Ciancio S. Expanded and future uses Histologic probe penetration in healthy of mouthrinses. J Am Dent Assoc. appointment cus and inflamed peri-implant tissues. Clin 1994;125(suppl 2):29S-32S. c. is used for monitoring the health of the d. a and b Oral Implants Res. 1994;5:191-201. 46. Garg AK, Duarte F, Funari K. Hygienic 23. van Steenberghe D, Klinge B, Linden maintenance of dental implants: the implant U, et al. Periodontal indices around key to long-term success. J Practical d. all of the above 6 Presence of a fistula may indicate ______. natural and titanium abutments: a lon- Hygiene. 1997;6:13-20. a. fracture of the implant gitudinal multicenter study. J Periodontol. 1993;64:538-541. Radiographic monitoring of implant bone b. pathologic process associated with the 24. Quirynen M, van Steenberghe D, 2 levels should be performed ______. implant Jacobs R, et al. The reliability of pock- et probing around screw-type Dr. Silverstein is an associate clin- a. every 12 to 18 months c. A fistula cannot be associated with the implants. Clin Oral Implants Res. ical professor of periodontics at the b. 3 months following restoration of the implant because the implant is not a bio- 1991;2:186-192. Medical College of Georgia in 25. Mombelli A, Marxer M, Gaberthuel T, implant logical device. Augusta. He is on the editorial et al. The microbiota of osseointegrat- c. at each hygiene appointment d. a and b ed implants in patients with a history of boards of Practical Periodontics periodontal disease. J Clin and Aesthetic Dentistry, Dentistry d. every 18 to 24 months Periodontol. 1995;22:124-130. Today, and Esthetique, a direct-to- 7 With regard to implants, electric toothbrush- 26. Artzi Z, Tal H, Moses O, et al. Mucosal consumer aesthetic topics publica- es ______. considerations for osseointegrated tion. He also maintains a private 3 Peri-implantitis has been associated with implants. J Prosthet Dent. practice limited to periodontal care ______. a. should not be used, as they may loosen 1993;70:427-432. and dental implants in Atlanta at a. bacterial plaque fixation screws 27. Cochran D. Implant therapy I. Ann Kennestone Periodontics, PC. He Periodontol. 1996;1:707-791. b. mobility of the implant b. may damage the implant surface 28. Papaioannou W, Quirynen M, Nys M, recently published the textbook, c. are a good adjunct to home care Principles of Dental Suturing: A c. gingival inflammation et al. The effect of periodontal param- d. are not as effective as a manual tooth- eters on the subgingival microbiota Complete Guide to Surgical Closure. d. all of the above around implants. Clin Oral Implants Dr. Silverstein can be reached at brush Res. 1995;6:197-204. (770) 952-5432, via fax at (770) 29. Silverstein LH, Meffert RM, Jeffcoat M, 952-3011, or by e-mail to kenpe- 4 Bone loss of 1.5 mm during the first year et al. Clark’s Clinical Dentistry. Vol 5. St following placement of the implant is ____. 8 The peri-mucosal seal around implants ver- rio@bellsouth.net. Louis, Mo: Mosby Year Book; chap sus natural teeth ______. 62A Clinicians guide to peri implantol- a. considered a sign of peri-implantitis ogy. 1998. Dr. Kurtzman is in private practice b. normal a. is similar 30. Garnick JJ, Silverstein L. Periodontal in Silver Spring, Md, and is an b. is weaker around natural teeth assistant clinical professor at the c. a sign of occlusal overload of the probing: probe tip diameter. J Periodontol. 2000;71:96-103. University of Maryland School of implant c. is weaker around implants 31. Garnick JJ, Silverstein LH. Clark’s Dentistry, Department of Restor- d. both a and c d. varies from patient to patient Clinical Dentistry. Vol 3. Philadelphia, ative Dentistry. He is on the editori- Pa: JB Lippincott; chap 2B Periodontal al board of the Journal of Oral probing. What does it mean? 1997:1- Implantology, an assistant editor of 15. 32. Misch CE. Contemporary Implant the International Magazine of Oral Dentistry. St Louis, Mo: CV Mosby; Implantology , and editor of the 1993:20-28. Maryland Chapter newsletter of the 33. Roberts WE, Garetto LP. Bone physi- Academy of General Dentistry. He ology and metabolism. In: Misch CE, can be contacted at dr_kurtz- ed. Contemporary Implant Dentistry. man@maryland-implants.com. 2nd ed. St Louis, Mo: Mosby; 1999:225-237. 34. Oh TJ, Yoon J, Misch CE, et al. The causes of early implant bone loss: myth or science? J Periodontol. 2002;73:322-333. Continuing our “Journey of Excellence” 35. Misch CE. Density of bone: effect on MARCH 2006 • DENTISTRY TODAY