More Than Maintenance

How Implant Care For The Dental Hygienist Has Evolved

By Lynn Mortilla, RDH

Dental professionals share a heightened awareness regarding the success of dental implants as a treatment option for missing teeth. The growing popularity of dental implants is a two-fold result of community/patient education and education of dental professionals. The growth of dental implant therapy has re-defined the role of dental team members in respect to what their specific role will be with patients during each phase of care.

How do we define the role of the dental hygienist with implant patients? A critical function is the initial evaluation of patients as potential implant candidates. Though many people now know about dental implants, many still don’t choose them as a treatment option.

The communication and conversations with potential implant patients can lay the foundation for case acceptance. Communications will often begin with why a patient may need an implant. What are the consequences of not having an implant? Why is implant therapy a good option for a particular patient? Are there adjunctive or alternative forms of therapy/treatment that can be utilized? It is very important for all auxiliaries to know why implants work, how well they work, and to understand all aspects of implant care so communications and explanations to the patient, based on the doctor’s diagnosis, is seamless.

If the patient accepts treatment, the hygienist will then be responsible for educating the patient about oral care during the surgical and prosthetic phases of treatment. Understanding the surgical treatment the patient will undergo and types of restoration to be placed is crucial for recommending the appropriate oral hygiene techniques during healing phases. Clinical hygiene and home hygiene procedures need to be effective but non-invasive so healing tissues are not disturbed. At the same time the patient must be aware that gentle debridement will only be effective while tissues are healing. Once healing and restoration are complete, a new hygiene routine will need to be established, learned, and complied with.

Once the teeth are restored, it is vital for a hygienist to be able to thoroughly assess oral conditions to recognize changes that may indicate potential implant and/or implant prosthetic problems. The dental hygienist is indispensable in identifying negative findings or changes from baseline. Routine use of a checklist or a form to chart changes is extremely helpful and will assist in communication between care providers. Early changes from baseline are often early indicators of a complication that will require further evaluation and possible intervention or correction.

Research has proven that smoking, certain medical conditions, active periodontal disease, plaque, poor oral hygiene, excess cement, excessive biomechanical stress, untreatable infection, and/or iatrogenic treatment of surfaces around an implant abutment can be detrimental and contribute to implant and/or prosthetic complications and failures. Once identified, the doctor should be alerted to any changes so assessment and diagnosis of the problem can be initiated. Disease, problems, and infection need to be addressed swiftly to avoid progression which may lead to the failure of the implant.

Long-term implant success comes from the interaction of many variables, one of which focuses on maintenance protocols. Dental implants and the abutments upon which restorations are placed are commonly made from titanium and titanium alloys. Titanium and titanium alloys are soft metals highly susceptible to scratching and surface alterations. Additionally, the materials currently used for restoratives are also susceptible to alternations and care must be taken to also keep the restorative material unspoiled.

Traditional hygiene maintenance procedures can be detrimental to implant maintenance protocols. Dental hygiene maintenance of implants must rise to a new level in order to effectively maintain implants while also safeguarding the integrity of the implant and restoration. The instruments selected to perform maintenance techniques are critical to maintain unaltered surfaces and avoid tissue trauma.

So how should an instrument be chosen for maintenance? It is our responsibility to rely on evidence for the answer to what is safe and effective.

Countless pieces of research have shown that stainless steel instruments, titanium instruments, as well as any instrument with glass and graphite fillers can alter or scratch implant abutment surfaces and produce a rough, pitted surface ideal for harboring bacterial plaque and calculus. Recently, a review of the literature confirmed these findings quoting, “Titanium curettes caused a roughening of the implant surface in all studies. Non-metal instruments and rubber cups seem to be the instruments of choice for the treatment of a smooth implant surface, especially if the preservation of surface integrity is the primary goal. Similarly, for rough implant surfaces, non-metal instruments and air abrasives are the instruments of choice, especially if surface integrity needs to be maintained. Metal instruments and burs are recommended only in cases where the removal of the coating is required.”1

Additionally, documented evidence demonstrates an increased relationship between an altered (rough) surface and the higher bacterial counts. Research has noted, “Scaling the implant with a titanium-alloy curette produced the roughest surface ... it is possible that this roughened surface may be more conducive to the formation and retention of bacterial plaque, and perhaps in this way result in an adverse biologic response caused by plaque-induced inflammation.”2

Higher bacterial counts may contribute to the development of peri-implant mucositis and peri-implantitis.³

Instrument tip designs should provide the clinician adequate options to address the patient’s individual implant abutment and prosthetic components’ needs. The instrument should offer some of the same basic features as a metal scaler or curette, while being made of an implant friendly/compatible material. Some qualities to assess are: familiar design, ergonomic handles, rigidity to withstand scaling pressure without the risk of fracture or breakage, the ability of the instrument not to leave any residue behind,4 blade dimensions that allow easy and atraumatic access to implant abutment angulations and tissue tightness, and lightweight to avoid hand and wrist fatigue. Some implant instruments have been shown to achieve optimal implant maintenance results while preserving abutment and prosthesis surfaces without altering or scratching.⁵ Polishing with a rubber cup and non-abrasive toothpaste, fine prophy paste, and tin oxide have all been shown not to alter titanium implant surfaces.

The growth in the placement and restoration of dental implants is continuing at a steady rate. Advances in technology and research as well as understanding of the biological and biomechanical relationships keep implant therapy very dynamic. The utilization of dental implants increases the potential for complications and long-term maintenance challenges. Parameters for evaluation, assessment, and clinical procedures for maintenance are continually evolving, and the role of the dental hygienist in the care of implants will continually adapt to these changes. The dental hygienist must be diligent to frequently review and adapt treatment protocols based on current research and patient needs in order to provide the best comprehensive care to dental implant patients. RDH

References

1. Louropoulou A, Slot DE, Van der Weijden FA. Titanium surface alterations following the use of different mechanical instruments: a systematic review. Clin Oral Implants Res. Vol 23, Issue 6, June 2012, Pages: 643–658.
2. Dmytiyk, Fox, Moriarty. The Effects of Scaling Titanium Implant Surfaces With Metal and Plastic Instruments on Cell Attachment J Periodontol 1990; 61:491-496.
3. Bollen CM, Papaioanno W, Van Eldere J, et al: The influence of abutment surface roughness on plaque accumulation and peri-implant mucositis, Clin Oral Implants Res 7:201-111, 1996.
4. Ramaglia L., di Lauro AE, Morgesse, F. Squillace A. Profilometric and standard error of the mean analysis of rough implant surfaces treated with different instrumentations. Implant Dent. 2006 Mar;15(1):77-82.
5. Hallmon WW, Waldrop T, Meffert RM, et al. A Cooperative Study of the Effects of Metallic, Nonmetallic, and Sonic Instrumentation on Titanium Abutment Surfaces. Int J Oral Maxillofac Implants 1996;11:96-100.

Performing Prophylaxis On Implants

A unique dilemma exists in choosing a safe instrument to perform a prophylaxis on a patient who has been restored with implants and presents with calcified accretions or excess cement. This begs the question what accretions are we trying to remove?

Owing to lack of porosity, the adherence and tenacity of calculus around implants is generally less than around natural teeth. When removing accretions on an implant abutment and restoration, the clinician should assure care is taken not to rip or damage the permucosal seal. When calculus is subgingival, attention should focus on carefully placing the blade atraumatically under the deposit with careful instrumentation consisting of using exploratory strokes and light pressure, in a coronal, semi-circular direction.

Clinicians may find it helpful to dry accretions prior to removal for enhanced patient comfort and ease of blade engagement. When there is bone loss around an implant, extreme care must be taken by the hygienist to avoid instrumentation in the threaded area of the implant surface since alterations to the implant surface can cause complications. These areas need the attention of the doctor and assessment for reparative procedures.

LYNN MORTILLA, RDH, is an Adjunct Clinical Instructor in the Department of Periodontology and Oral Implantology Kornberg School of Dentistry at Temple University. She is the Executive Director of the Association of Dental Implant Auxiliaries (ADIA) and Director of Operations for the International Congress of Oral Implantologists (ICOI).