of Implant Supported Dentures

Transcription

1 Chapter 7: Professional Care and Patient Maintenance of Implant Supported Dentures 2 CE hours By: Sharon Boyd, RDH Learning objectives Upon completion of this course, the learner should be able to: Choose appropriate instruments during prophylactic and therapeutic care appointments. Evaluate the health of tissues surrounding dental implant abutments. Determine appropriate home care methods for patients that wear implant-supported prosthesis. Create a re-care plan that is appropriate to the implant patient s needs. Introduction Approximately 3 million Americans currently have dental implants, and another 500,000 are expected to get implants every year (1). Thus, dental hygienists and dentists are expected to understand how to properly manage their implant patients during preventive care appointments as well as provide proper education for home care purposes. If not, peri-implantitis may develop and impact the success of the implant prosthesis, resulting in premature failure. Dental implant overdentures are removable prosthesis that are stabilized by dental implant systems. In most cases, the overdenture is supported by a ball or bar retention device and held into place using clips or locators attached to the removable denture. Ball retention systems involve individual implant abutments with locators placed into the denture, where the implants align and snap into place. Bar-retained overdentures include housings inside of the denture, which clip over the bars suspended between the dental implants. Identify appropriate oral hygiene aids in addition to traditional toothbrush and floss. Calculate instrumentation techniques to be used on implant patients receiving periodontal scaling and root planing. Adapt probing methods as necessary from traditional periodontal probing to altered pocket charting that is implant-specific. List types of implant-supported denture options used frequently in dentistry. Determine how frequently radiographs should be taken on a patient with a fixed implant prosthesis. Fixed dentures, otherwise known as non-removable, hybrid, or fixed detachable dentures are permanently anchored onto the jaw using a screw system. This permits the prosthesis to be removed if necessary by the dentist, but not the patient. Commonly known as all-on-4 dentures, these fixed dentures have gained a tremendous amount of popularity among modern dental patients as a convenient alternative to traditional removable dentures and overdentures. Because of the types of implant-supported dentures used in patient care, dental professionals and patients should understand the methods, techniques, and oral hygiene aids that are most appropriate for maintaining the various types of prosthesis. Removable implant overdentures and fixed hybrid dentures are similar, but the care methods for the oral and gingival health of the patient vary. Appointment options Maintenance of patients wearing implant-supported dentures is similar to managing patients that are periodontally compromised. However, the diagnostic process is much different (2). Managing patients with implant-supported dentures will depend on the current health of Prophylaxis/maintenance Preventive care appointments are more maintenance than preventative. Initially, patients wearing an implant-supported denture should have maintenance appointments at least every 3 months after the prosthesis is placed. However, they may need to be seen as frequently as every month until adequate re-care and proper home oral hygiene habits are established. The frequency of these visits allows the dental professional to evaluate any changes in the oral health of the patient, including possible complications or risks associated with the health of the dental implant. More frequent visits minimize the risk of failure for the implants supporting the denture (3). Visits should be frequent for the first year following the placement of the denture, but can then be more sporadic. gingival and peri-implant tissues in their mouths, as well as whether or not any teeth still exist in the opposite arch. Like patients with natural teeth, implant patients with fixed prostheses require regular preventive care to avoid peri-implantitis and other forms of implant risks. If the patient s home care is appropriate, he or she may be placed on a 6-month recall schedule after a year. It is essential that no more than 6 months pass between preventive care appointments for at least the first 2 years after the implant placement. It is recommended that only a fine grit polishing paste be used with selective polishing techniques, using a rubber cup around the implant to remove soft debris and stains. Tin-oxide can also be used, or the practitioner can purchase a polishing paste that is formulated for the specific use of implant polishing. Prophy angles with rubber points may also be useful for selective polishing along harder-to-reach areas and between implants. Air polishing implants may be too abrasive, but it has been shown to be safe enough for maintenance of healthy implant patients. Page 98 Dental.EliteCME.com

2 Debridement A full mouth debridement may be necessary when heavy plaque and calculus is in the patient s mouth. This may be due to poor patient care or a lapse in prophylactic care appointments. If heavy calculus deposits extend over the implant prosthesis or in supra gingival areas of the implants, a debridement may be necessary before an exam can be completed. Periodontal scaling and root planing In most cases, scaling around an implant should be restricted to areas supragingivally or immediately surrounding a deposit. However, periodontal scaling and root planing (SCRP) may be needed when existing teeth are on the opposite arch, or if peri-implantitis impacts the areas surrounding the implants that are supporting the denture. When implants are involved in an SCRP procedure, appropriate instrumentation is essential. Recognizing implant failure During each appointment, whether it be preventive or therapeutic, each individual implant should be assessed for signs of failure. More often than not, this is noted by signs of bone loss over 1 mm during the first year after implant placement, or greater than 0.2 mm per year during subsequent years (5). Other symptoms to be aware of include: Implant mobility. Bleeding on probing. Instrumentation selection and techniques Although scratching the surfaces of implants has not yet been shown to increase the risk of peri-implantitis, it should still be avoided; this is why air polishing is highly debated and not recommended for use on these patients (4). During the debridement, it is important to note the health of the gingival tissue surrounding the implants. If exudate or suppuration is present, a peri-implant infection may be the cause. A debridement is usually only necessary due to a lapse in care caused by a delay in preventive care (prophylactic) appointments or extremely poor oral hygiene. Plastic instruments are flexible, yet durable enough to remove both hard and soft deposits from implant surfaces (4). They can also be sharpened, if they are reinforced with graphite. Do not use traditional ultrasonic instruments while cleaning implants, as this could damage the surface of the titanium. Instead, implement an implant-appropriate ultrasonic tip to use during the SCRP. Presence of purulent exudate around the implant. Peri-implant radiolucency. A dull sound during percussion of the implant. Implant patients that smoke or use tobacco products are more likely to experience prosthetic failure than healthy, non-smoking patients, but all individuals should have the integrity of their implants assessed to avoid potential complications. There is also some concern that the titanium oxide surface layer could allow for corrosion of the implant if it is altered through instrumentation. Thus, selection of implant-specific instruments is important for each patient. Inspection of the removable prosthesis during appointments For removable overdentures, the prosthesis attachments should be inspected during each appointment. This includes O-rings, locators, and clips. Most O-rings and locators will need to be replaced annually, but clips only require replacement if they are damaged. Record the color of the attachment in the patient s chart to monitor the integrity of the locators from visit to visit. Chemotherapeutic agents Site-specific chlorhexidine irrigation can help the patient manage isolated areas of peri-implant inflammation. Patients may also need to be given a disposable oral irrigation device to use around specific areas, to limit staining caused by the antiseptic. Chlorhexidine, plant alkaloids, and phenolic agents have all been shown to produce only minimal alterations to implant surfaces (3). Implementing chemotherapeutics early can be useful in slowing or reversing inflammation (3). These can include rinses such as peroxide, chlorhexidine, or locally applied medications such as Arrestin or PerioChip. Curettes Because dental implants are more likely to be affected by inflammation caused by plaque accumulation than natural teeth are, instrumentation selection and use is extremely important (3). Conventional scalers and curettes are capable of altering the surface of titanium dental implants by scratching the outer layer of the titanium. Thus, scalers and other types of instruments that are used to clean implants should be made of material that does not damage the implant or create small scratches that could harbor bacteria between appointments. Ensure that the patient is removing their overdenture nightly to prevent infections throughout their mouth. Examine the denture to see that the patient is using appropriate home hygiene equipment including soaking the denture overnight in a cleansing solution, followed by brushing the soft debris away each morning. If chemotherapeutics are applied with a dispenser, the delivery method must use a non-metallic cannula with rounded tips to prevent tissue trauma or surface damage to the implant. Carefully insert the tip of the cannula into the implant sulcus without disturbing existing tissue attachment. The use of micro-encapsulated minocycline or chlorhexidine gel can be used in peri-implantitis, and has been shown to reduce both pocket depths as well as bleeding on probing for up to one year after placement. (3). In chemotherapeutics that contain tetracycline-loaded fibers, the medication is slowly released over a 10-day period, lengthening the amount of time that medication is delivered to the peri-implant infection. Scalers that are appropriate and safe to use for removing both soft and calcified buildup include those made from plastic, graphite, nylon, titanium or covered in a Teflon coating. Dental.EliteCME.com Page 99

3 These materials will not scratch, harm, or alter the titanium surface when used for instrumentation purposes. Plastic scalers may leave some residue behind after cleaning around the dental implant. If the instrument tip is reinforced with graphite or gold, it can be sharpened (3). Unfortunately, gold scalers can easily be worn down or altered in shape when scaling rougher areas. This presents itself as a risk, as underlying metals may be exposed and thereby harm the implant being scaled. Resin scalers are also appropriate for use on implants. Refrain from using stainless steel scalers, as they may alter the titanium implant in a way that increases their susceptibility to corrosion. In fact, dissimilar metals like stainless steel can increase the number of gingival fibroblasts that are removed from the peri-implant area during Use of manual scalers Typically, calcified deposits are much easier to remove from smooth titanium implant surfaces than calculus attached to natural teeth. (2) Because no microscopic textures or surface changes on the titanium implant exist, the calculus is far easier to manually sweep away. If the deposit is found to be tenacious and difficult to remove, a tartar softening product may be used to loosen the debris and make it easier to lift away. Before scaling away calcified deposits, air-dry the visible buildup. This will usually make it easier to sweep the deposit away with the hand scaler using minimal effort. Use short working strokes and walk the scaler around accessible implant surfaces. Only light pressure is necessary (2). Ultrasonic scalers Traditional ultrasonic instruments can significantly alter the titanium surfaces of dental implants. Multiple scratches, grooves, and rough surfaces can be left in place following the use of a conventional ultrasonic scaler in these sites. These increased rough surfaces thereby harbor elevated levels of plaque biofilm, which creates a susceptible environment for future peri-implant infections, jeopardizing the retention and success of the implant prosthesis. Although very minor scratches can be polished away, large and significant damage caused by metal ultrasonic tips cannot. Polishing methods It is not necessary to polish the exposed surfaces of titanium implant. However, polishing may be useful for removing excessive plaque or debris during the appointment. Use the rubber cup to deplaque prior to scaling, if preferred, as it is estimated that polishing alone will remove about 90% of all deposits over the implant surface. If a rubber cup is used for polishing, refrain from using traditional gritty or abrasive polish. Instead, select tin oxide slurry, aluminum oxide or a nonabrasive polishing paste that is specifically for dental implant use. All polishing paste should be free of Acidulated Phosphate Fluoride. Generic toothpaste may also be used. (1) In cases where no polishing paste is needed, chlorhexidine may be used instead. Usually, the manufacturer of the implant abutment will prepare it with a polished finish that is difficult to alter using a rubber cup prophy angle (3). scaling, compared to using a titanium-alloy curette. This alters the retention of the implant by the peri-implant gingiva. Using a titanium or plastic scaler will help preserve the fibroblasts surrounding the implant. In some cases, disposable scalers can also be used. However, the instrument should not be bulky enough to interfere with the gingiva in the peri-implant area surrounding the abutment. Select an appropriate curette that allows for adaptation within the sulcus surrounding the implant. Some practitioners find that using titanium scalers is more effective in removing calcified deposits over plastic scalers, although plastic scalers can still be successfully and easily used for the removal of soft plaque biofilm. Using scalers along the implant is similar to the method used for scaling natural teeth. Close the blade completely against the abutment before sliding it subgingivally below the deposit. When scaling around fixed implant prosthesis like an All on 4 denture, instrument adaptation can prove to be more difficult. Scale what is accessible. Once properly positioned, open the scaler gently and make short working strokes appropriate to the needs of the implant root. Again, only light pressure is necessary, as the deposit should come off much easier than one on the surface of a natural tooth root. In most cases, calculus is found supragingivally along dental implants, rather than subgingivally (3). In fact, most deposits can simply be removed with a prophy angle. Refrain from scaling subgingivally within the implant sulcus unless infection or deposits are present. Plastic ultrasonic tips prevent significant alteration to the titanium surface during scaling. Although plastic tips may create some changes in the implant surface, after the surfaces are polished there is usually no noticeable difference. Plastic ultrasonic tips are generally more effective in removing biofilm than manual plastic curettes. (1) Using a carbon fiber, plastic, or plastic-coated ultrasonic allows dental practitioners to maintain smooth implant surfaces during prophylactic procedures (2). Metal ultrasonic or piezo tips may also be covered with plastic inserts for ultrasonic cleaning purposes. This prevents the need to buy additional instruments or change tips throughout the procedure. Light air polishing can be performed using glycerine powder. Air polishing may be preferred if leaving residual rubber particles is a concern following rubber cup polishing. Although more recent research supports air polishing safety, some dentists still consider air polishing to be contraindicated around all dental implants as this has been the train of thought for quite some time. Some studies show that air-abrasion is completely safe, while others suggest it may damage titanium surfaces or even lead to detached tissues in the peri-implant area. Due to the conflicting research available, practitioners should verify with implant manufacturers whether or not air abrasives are appropriate for use around specific designs of implants used within their office. Page 100 Dental.EliteCME.com

4 Lasers The use of lasers around implants for peri-implant infections is promising. Using lasers around implants may reduce the depth of periimplant pockets, as well as bacterium levels (8). Unfortunately there are still many mixed studies regarding the success and safety of dental lasers Professional cleaning of the denture prosthesis If deposits are present over the surface of a removable denture, place the denture into a zip-top bag filled with stain and tartar removal solution and place it into the ultrasonic machine according to manufacturer s directions. After being thoroughly rinsed, scrub away any remaining deposits. Light ultrasonic instrumentation may also be used. Avoid abrasive rubber cup polishing if possible, to prevent scratches in the surface of the overdenture. Polish abutment surfaces as appropriate before having the patient place the removable overdenture back into their mouth. surrounding implant sites. Multiple appointments may be necessary for laser therapy before desirable results are achieved around the prosthesis (9). It is acceptable to work around fixed removable prosthesis without having them removed during the appointment. However, these prosthesis should be removed intermittently for inspection and thorough cleaning as the need arises. In most cases, the fixed prosthesis will typically not be removed during re-care appointments unless complications exist. This means that it is vital for providers to be competent in working around the prosthesis during most prophylactic visits. Periodontal probing around implant supported dentures Probing around implants requires some modification in the way the data is interpreted as well as recorded. For healthy teeth, probing depths of 3 mm or less are desirable. However, a dental implant can have healthy readings anywhere up to 5 mm. When dental implants have pockets deeper than 5 to 6 mm, they are more likely to fail. In fact, over 50% of failed implants have pocket deeper than 6 mm. Implant experts agree that about 1 to 1.5 mm of bone loss occurs within the first year of placing the dental implant, and an additional 0.1 to 0.2 mm each year after. If the patient presents with bone loss amounts more than this average, it should catch the attention of his or her dental practitioner. It is recommended that implants be probed within 3 months of placing the prosthesis, and every 3 to 5 months thereafter. (3) After probing depths have been stabilized for one year, it is recommended that only the buccal and lingual surfaces of implants be probed on a routine basis. This is also easier to manage when patients wear fixed denture prosthesis. Interproximal bone height should be observed with radiographs. (2) This allows for minimal disruption of the perimucosal seal with the periodontal probe. Probing techniques When probing along an implant, it is important to avoid insulting the perimucosal seal. Gently sweep the probe into the sulcus, but take note to avoid pressing the probe into the extreme deepest point of the pocket. In addition to recording pocket depth, the appearance of the periimplant tissues is also key to indicating a healthy environment. Tissues surrounding the implant should be keratinized, as a lack of keratinized tissues are more susceptible to peri-implantitis (8). The appearance of the tissues should be light pink, but firm. When the tissues are not keratinized enough, the area around the implant is more likely to be impacted by pathogenic microorganisms. Radiographs Diagnostic x-rays play an important role in monitoring the health of patients with dental implants especially those that support fixed or removable denture prosthesis. The radiographic imaging allows dental providers to evaluate bone quality, including changes in the crestal bone height surrounding the implants. In fact, x-rays may be the single most important tool that is used to assess the success and heath of the supporting implants during a patient s re-care. Initially, vertical bitewings should be taken on a frequent basis as often as every 6 to 8 months for new implant patients (3). Others suggest taking bitewings as frequently as every 3 months during the first year following implant installation. Peri-apical films can be used on the front teeth if preferred, but otherwise, vertical bitewings are adequate for routine use. As long as images of the crystal bone are included in the radiographs, either one will be acceptable. The key is to ensure that each one of the supporting implants is properly recorded during each series of films. These images should be compared to the original radiographs that were taken immediately after the placement of the implants. This is Probe material The probe of choice can be either metal or plastic. There have yet to be any studies that indicate damage to implant surfaces by traditional probes, but many sources still claim that a metal probe could potentially harm the peri-implant site or scratch the surface of the titanium. However, a plastic probe may be more effective in areas where contour is difficult to access with a rigid metal probe. Less force should be used than what is appropriate for probing natural teeth. Otherwise the gingival attachment could possibly be damaged. However, if signs of peri-implantitis like bleeding or purulent exudate are present, it is crucial that an accurate pocket depth is recorded. done so that crestal bone levels can be carefully measured in order to identify early or advanced bone loss. Assuming that there are no unfavorable changes in bone height or quality after the first few visits, radiographs can be taken much less frequently during subsequent visits in some cases, even as long as 3 years between each patient s appointment.(3). If the patient exhibits any evidence of bone loss greater than the accepted and expected range of 1 mm the first year following placement; or 0.2 mm during subsequent years; or has symptoms of peri-implantitis, then radiographs should be continually taken at least every 6 months during recall appointments until signs of the infection or bone loss cease. Although radiographs are used to identify signs of bone loss around the implants, they should also be used to screen for other types of oral pathology such as: Lesions throughout the jaw. Foreign objects. Abnormal growths. Dental.EliteCME.com Page 101

5 Following traumatic events. If cone beam computed tomography (CBCT) equipment is readily available, it can be utilized to more effectively measure cortical bone Patient home care methods Research shows that controlling plaque biofilm levels around dental implants is vital to maintain the health of the restoration. (4) It is just as important as caring for natural teeth. Because of this, it is extremely important that implant patients understand their role in the maintenance of their oral health as it relates to the success of their implants over the course of their life. Unfortunately, many dental implant patients lack adequate oral hygiene habits, which is most likely a significant contributing factor as to why they are replacing missing teeth in the first place. Oral hygiene assessment It is important for each implant patient to receive an individual oral hygiene evaluation, assessing his or her home care methods. Modifications or re-evaluations at subsequent appointments may be necessary. Have the patient stand in front of a mirror (or hold a hand mirror) while he or she shows you how to remove biofilm from the appliances using various types of oral hygiene aids. During the oral hygiene assessment, patients should be instructed both visually and verbally on the cleaning methods appropriate around their new prosthesis. If the patient s methods are inadequate, trade places with the patient, allowing him or her to watch in the mirror while you demonstrate how to properly access areas around the implants, fixed (or removable) prosthesis, as well as methods for oral hygiene aids such as floss threaders and proxa-brushes. Using an intra-oral camera during prophylactic appointments or exams can improve the patient s knowledge of what areas require additional care. Toothbrushes Both manual and electric toothbrushes can be used for effective plaque removal around fixed dentures.(2). The key is to use the brush properly, along the margin of the gingiva to lift soft deposits from the implant surface. Both soft and extra soft brushes can safely be used to clean titanium implants without risk of surface damage. If the patient has limited dexterity, it is best to recommend the use of an electric toothbrush for oral hygiene. A gentle toothbrush should be used twice each day along the fixed prosthesis or visible implants. Tufted brushes may be useful along bar Interproximal cleaners and tufted brushes Cleaning around the neck of the implant along the gingival margin can be carefully performed using oral hygiene devices such as an interdental brushes or floss. Various types of interdental cleaners may provide improved access and biofilm removal under fixed implant prosthetics such as an All on 4 denture. The interproximal cleanser should be used both under the prosthesis, as well as around and under the peri-implant crevice (8). End-tuft brushes may be too bulky for some fixed prosthesis, but can be used to remove larger pieces of food or plaque debris along the contour of fixed dentures. However, tapered brushes may be most appropriate for cleaning around cross bars under removable implant prosthetics. If the brush has exposed metal surfaces, extreme care should be taken. Otherwise it may be possible to scratch the titanium abutment with the surface of the brush core. thickness and quality around each implant. However, CBCT is not mandatory for routine maintenance of implant patients within a general care facility. A complete overhaul on the patient s oral hygiene habits may be necessary. Care providers should assume that the patient does not have the information or tools needed to begin immediate and adequate home hygiene. Thus, a rigorous oral hygiene educational plan should begin. Alternately, patients who are overzealous about their oral hygiene methods may create tissue trauma around their implants by being too aggressive with their oral care techniques. Proper instruction on implant and denture care is essential to prevent failure of the fixed prosthesis due to tissue trauma or recession. Identify areas of biofilm deposits, inflammation, and redness that exist due to inadequate oral care, followed by showing the patient the appropriate way to clean those areas. Record the image in the patient s file, so that it can be compared to subsequent visits for patient educational purposes. Assessment of removable implant prostheses Instruct the patient on how to evaluate the overdenture for signs of biofilm collection and wear. Removable overdentures should be cleaned with a separate denture brush and denture cleanser than those retained within the mouth permanently. Once the patient removes the overdenture, inspect the prosthesis for any complications, such as broken or loose attachments on the denture or implant abutments. Attachments such as O-rings and locator caps can wear out, requiring them to be replaced fairly frequently to retain a snug fit. Most removable denture locators and O-rings need to be replaced once per year, and clips replaced only as necessary. (8) connectors. Whether the patient is using a traditional brush or a tufted brush, implant patients should follow the traditional Bass toothbrushing technique; tilting the bristles toward the gum lines at a 45-degree angle and applying only enough gentle pressure to produce light blanching of the tissues. Although electric toothbrushes can be used, abrasive automatic toothbrushes may be too aggressive for healthy gum tissues. Recommend that your patients use a quality sonic or ultrasonic electric brush with soft or extra-soft bristles. Advise your patients to select interproximal brushes that are constructed from or coated with plastic to prevent implant damage or tissue trauma with a metal wire. Nylon brushes are also safe to use, as they will not cause scratching to either the implant or the implant prosthesis. Interproximal brushes should be chosen based on the size and space around the embrasures. In addition to tufted brushes, some patients may also prefer foam tips or wooden picks for plaque removal. Rubber-tipped stimulators can assist in maintaining healthy keratinized tissue along the implant retention bars or along a fixed denture. Healthy keratinized tissue promotes a healthy peri-mucosal implant seal. Patients should be educated on the proper way to use the rubbertip stimulator, so as not to damage the gingiva with the pointed end. The goal is to place the stimulator horizontally along the gum tissue to massage the gingiva. Only light pressure is needed, producing mild blanching similar to that achieved during Bass method brushing. Page 102 Dental.EliteCME.com

6 Oral irrigation/water flossing Water irrigation or water flossing has been found to be extremely successful in biofilm removal within the sulcus surrounding natural teeth as well as along the surfaces of dental implants. It is safe to use water flossers, at appropriate mild pressure levels, around dental implants and fixed full mouth prosthesis. However, the stream of water should be placed perpendicular to the implant prosthesis to avoid horizontal irrigation into the peri-implant seal, and thus possibly causing damage to the area. In many cases, using an oral irrigator may be more effective for cleaning hard-to-reach areas around and underneath the fixed implant prosthesis. It may be the most effective way for patients to clean around their fixed dentures. Be sure that the water flosser has a nonmetal tip in the likelihood that it could come into contact with the implant abutment, so that scratches can be avoided. Although most people use oral irrigators only once a day, it is beneficial to have implant patients use the irrigation advice up to twice Floss and floss threaders Traditional floss may be too difficult for patients to access areas around their implants, unless the implant prosthesis is removable. For fixed dentures, a floss threader can be used to guide traditional floss or dental tape underneath the prosthesis. Tufted floss with a firm tip, such as super floss may make cleaning under a fixed implant prosthesis more efficient. This wider form of floss may be the method of choice in areas where larger spaces between implant retained prosthesis exist. However, some patients may find that it is too tight of a fit these wider variety of flosses under their fixed prosthesis. In addition to flossing along the interproximal areas of the implant, the floss should also be wrapped or looped around the abutment using a shoe shine method for cleaning the lingual and facial surfaces more efficiently. Once the floss is passed under the prosthesis, loop it around the other side and back to the facial side of the implant. Then, cross the floss one side over the other to create a flush circle around the abutment. Gently tugging on each end of the floss will result in a shoe Dentifrice Patients should avoid abrasive dentifrice such as baking soda and stain removing products, such as smoker s toothpaste. Recommend a non-abrasive toothpaste. Fluoridated over the counter toothpaste is acceptable to use. Although there are concerns about fluoride etching titanium, the lower concentrations found in store bought dentrifice has not been shown to impact the surface integrity of implants. Chemical agents If for any reason brushing or other mechanical hygiene steps are contraindicated, such as immediately following a surgery, advise the patient to use chlorhexidine instead of conventional toothpaste. Antiseptics can also be placed on floss for delivery along the marginal gingiva surrounding the implant abutment. Or, have patients dip their interproximal brushes or other types of interdental cleansers into non-alcoholic antimicrobial mouth rinse before using them along the margin of their implants. For patients that are susceptible to gingival inflammation, recommend placing the antimicrobial rinse onto a rubber-tip stimulator for application (8). Conclusion Managing fixed and removable dental implant prosthesis is very important for dental professionals, as implant are now regarded to be the standard of care for future tooth replacement. As more patients choose daily. Especially in the case of patients that wear fixed All-on-4 prosthesis. When implant patients use chlorhexidine inside of their oral irrigation device, it can reduce bleeding by up to 87% compared to using a rubber-tip stimulator dipped in a stronger concentration of the same antimicrobial rinse. Not only that, but oral irrigators used with chlorhexidine are three times better at reducing gingivitis than if the patient were to simply rinse their mouths (8). When patients use a bristle-tipped oral irrigation attachment, it can be up to 81% more effective at reducing bleeding around their dental implants, compared to just using floss, which is only about 33% effective (8). Thus, recommending an oral irrigator, along with a bristle-tipped irrigation attachment is highly recommended for implant patients with fixed prosthesis, such as All-on-4 dentures. shine flossing pattern around the individual implant. Release one end of the floss and then move along to the next implant site to repeat the process. Both dental practitioners and patients are often hesitant to place floss subgingivally around implants. However, floss should extend subgingivally to the point where some resistance is felt, as when flossing around natural teeth (3). Healthy implant pockets tend to be deeper than healthy pockets around natural teeth, which means flossing methods are unlikely to impact the level of peri-implant attachment. Fluoride Do not allow patients to use any types of pumice or dentifrice that contains stannous fluoride, or acidulated phosphate fluoride over 3.0 (8). Some studies suggest that fluoride ions create unwanted surface changes on titanium materials, such as that used in dental implants. However, patients may continue using over the counter fluoridated toothpaste for their everyday home hygiene purposes. One study simulated approximately 10 years of brushing with fluoridated dentrifice, and measured the levels of S. mutans adhesion to the titanium surfaces. The experiment showed that bacterial levels were the same on titanium surfaces brushed with fluoride as those where non-fluoride dentrifice were used (9). Antimicrobial rinses such as chlorhexidine gluconate or chlorine dioxide can also be diluted and placed into water irrigators for oral irrigation (8). Have patients dilute the chlorhexidine or other nonalcoholic mouth rinse into a 1:10 solution with tap water rather than using fully concentrated rinse inside of the irrigator. If an area of gingiva appears to have peri-implant disease or gingivitis, recommend applying an antimicrobial rinse at least twice daily, for 3 to 6 weeks until the area can be re-evaluated. Most of all, patients should avoid all mouth rinses that contain alcohol, or even whitening solutions. If an alcohol containing rinse is used, it may contribute to dry gingival around the implant site. implants for their oral health needs, re-care appointments will consist of a higher percentage of implant patients wearing fixed or removable overdentures. Dental.EliteCME.com Page 103

7 Both removable and fixed implant prosthesis are fairly easy to manage both in the dental office as well as at home. The key is to understand proper techniques, instruments, methods, and diagnostic approaches for implants compared to natural teeth. Implant patients are not simply re-care patients. They also sometimes require debridements, or even scaling and root planing appointments. Utilizing appropriate chemotherapeutic agents and instrumentation techniques will ensure that implant sites are healthy and able to continue supporting the prosthesis for a longer period of time. Most curettes, scalers, and ultrasonic instruments can be used, if they are made out of implant-friendly materials, such as plastic, titanium, or nylon. However, the majority of calculus deposits can be removed from implant surfaces simply by using a rubber cup polishing angle. Cleaning the actual denture prosthesis is very similar to the same methods used to clean traditional dentures. Probing around the implants should reveal pockets no deeper than 5 to 6 mm. These deeper pocket readings are still considered acceptable around the implant, assuming no signs of inflammation or infection is present. Once probing depths are stabilized for one year, it is recommended that only the buccal and lingual surface areas be probed at concurrent appointments. Radiographs are extremely useful in managing the support of fixed prosthesis. It is recommended that x-rays be taken every 6 to 8 months after implant placement until the alveolar levels have stabilized. Then, x-rays may be taken as infrequently as every 3 years. Patient education on the care of fixed and removable dentures is vital to implant success. Many people are too aggressive with their implants, or carry over inadequate oral hygiene habits, which contributed to the initial tooth loss to begin with. A proper assessment and follow up of their oral hygiene habits is key. As well as educating the patient on which oral hygiene aids to select, and how to use them around their appliance. Tools such as water flossers or interproximal brushes can be both effective as well as simple to use. Be sure the patient refrains from using abrasive dentifrice or products that contain APF over 3.0. Traditional oral hygiene methods such as flossing or using a water flosser may need to be significantly altered in order to prevent trauma or irritation to the periimplant site. Managing a patient with fixed or removable implant prosthesis may present itself more challenging than a traditional dental patient, but the process can be extremely rewarding. Due to the high success rating that most implants are capable of, the dental professional plays an extremely large role in the outcome of their patients future oral health. 1. Beck T. A periodontist s protocols to avoid dental implant complications: Part 2 - establishing an implant maintenance protocol. Perio-implant advisory. Retrieved online Oct 20, 2015 from Wadsworth L. Common Threads: Care and Maintenance of Implants. Dentistry IQ. Retrieved online Oct 20, 2015 from 3. Gulati M, Govila V, Anand V, and Anand B. Implant Maintenance: A Clinical Update. International Scholarly Research Notices. 2014;(2014):Article ID Todescan S, Lavigne S, Kelekis-Cholakis A. Guidance for the Maintenance Care of Dental Implants: Clinical Review. J Can Dent Assoc. 2012;27:c Fehrenbach MJ, Weiner J. Saunders Review of Dental Hygiene. 2nd ed. 6. Mailoa J, Lin G, Chan H, MacEachern M, Wang H. Clinical Outcomes of Using Lasers for Periimplantitis Surface Detoxification: A Systematic Review and Meta-analysis. J Periodontol Sep;85(9): Ashnagar S, Nowzari H, Nokhbatolfoghahaei H, Yaghoub Zadeh B, Chiniforush N, Choukhachi Zadeh N. Laser Treatment of Peri-implantitis: A Literature Review. J Lasers Med Sci Fall;5(4): Wingrove S. Focus on Implant Home Care. RDH Magazine. Retrieved online Oct 20, 2015 from 9. Fais L, Carmello J, Spolidorio D, Adabo G. Streptococcus Mutans Adhesion to Titanium after Brushing with Fluoride and Fluoride-free Toothpaste Simulating 10 Years of Use. Int J Oral Maxillofac Implants Mar-Apr;28(2): References Page 104 Dental.EliteCME.com

8 professional care and patient maintenance of implant supported dentures Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com. 1. Approximately 3 million Americans have dental implants. 2. One of the biggest risks for implant patients is the development of periodontal disease. 3. During the first year following implant placement, no more than 2.0 mm in bone loss should occur. 4. Micro-encapsulated minocycline capsules are acceptable to place within the implant sulcus if peri-implantitis is present. 5. Gold scalers can remove the number of gingival fibroblasts within the peri-implant area. 7. Nearly all dental implant patients have impeccable oral hygiene habits. 8. Implant patients should not use acidulated phosphate fluoride over 1.5%. 9. Non-alcoholic mouth rinses can be diluted into a 1:10 solution with tap water for use in irrigation devices. 10. No more than 6 months should lapse between preventive care appointments for implant patients for at least the first 2 years after the implant placement. 6. A healthy implant pocket may extend up to 7-mm in depth. DHOH02PCE17 Dental.EliteCME.com Page 105