By Elicia Lupoli, RDH, BSDH
Delia Casey of Straumann leads a roundtable discussion at CareerFusion.
In January, I came home from a life-changing dental retreat called CareerFusion. For that reason, I felt it was my duty as a dental hygienist, especially as one who has always advocated mentoring, to share some of what I learned. For me, it was how little I knew about dental implants, along with the materials used in our patients' mouths, their biocompatibility, and the armamentarium best designed to care for these materials.
I worked for seven years with an amazing prosthodontist who placed implants frequently, and I also worked for a terrific periodontist. During that time, I had treatment planned and observed numerous bone and soft-tissue grafts, along with removable and fixed prostheses, including hundreds of implant locater cases, and let's not forgot the maintenance of it all!
During this retreat, attendees participated in focus groups with some leading manufacturers of dental products and materials. The company representative would ask if we had heard of their company and/or product, and the group would proceed to discuss one or more of the products. Some key manufacturers included American Eagle Instruments, Crest/Oral-B, Straumann, Sunstar/GUM, Xlear/Spry, Voco, and many more.
I have been practicing for almost 14 years. When I sat down at one of these groups and started listening, I all of a sudden felt a little flushed and slightly embarrassed by some of the information I was unaware of. For example, I was unfamiliar with the name of a top dental implant company-Straumann. To be honest, before that focus group, I might have been able to name one dental implant company. However, ask me the name of a hygiene instrument company, and I can name every one.
This did not sit well with me.
I have been assessing, monitoring, cleaning, and maintaining implants, as well as treatment planning and recommending implants to patients for most of my career. I have discussed with patients the potential need for surgeries-bone grafts, sinus augmentations, and socket preservations. My employers and I would often regard this codiagnostic technique as laying down the foundation to prepare patients for their future treatment goals. The belief in our offices was that the more a patient hears the same suggestion from providers, the better it is accepted and understood. Dental implants have always been at the top of my list for tooth replacement.
I have always been confident in my discussions with patients about all phases of their restorative care during treatment planning, feeling that I possessed the knowledge of the entire process of procedures such as single or multiple implant restorations or soft tissue grafting for recession. Wrong! During these focus group discussions, I realized I had not one clue about the actual components in the restoration: parts, products, and materials.
The focus group was an eye opener and, yes, a blow to my ego! I was baffled that in almost 14 years I never once thought to ask an employer, "What company makes that dental implant?" "What type of bone graft is that?" "What is the difference between that grafting material and the next one, when you add a membrane to the site?"
Here are a few topics, facts, and suggestions that I learned from the focus groups that are valuable to us dental professionals, if you don't know already.
Understanding Implants
There are four different types of bone grafts according to specimen/sample/location:
- Alloplast (synthetic)
- Xenograft (animal donor)
- Allograft (human donor)
- Autograft (your own tissue)
Sunstar's Guidor easy-graft is an alloplastic bone graft and can be easily placed by general dentists. It is great for socket preservation and requires no sutures or membrane.1 There are many other uses too.
Straumann's Emdogain is a biologic used to stimulate all three cell types of the periodontium-cementum, periodontal ligament, and alveolar bone (regeneration). Emdogain should be the first choice by clinicians to use in soft-tissue grafting, or when an increase in clinical attachment levels is needed for intraosseous defects. 2
Straumann implants have a lifetime warranty. (What? I had no idea anything placed in the mouth could come with a warranty!) Know which of the two types of implants-bone level or tissue level-patients have, because it makes a difference for instrumentation. Know if the crown was cemented or screwed onto the abutment, because it makes a difference to be able to assess for oral health. Avoid using alcohol rinses such as chlorhexidine gluconate on implants with disease.3 The only FDA-approved, alcohol-free chlorhexidine gluconate rinse is GUM Paroex.4
Please learn more! Have you ever heard of primary and secondary stability? Pitch? All of this will make you an all-star of implant knowledge.
Implant Maintenance
The last topic was clarified for me at CareerFusion, since I want to discuss maintaining-specifically instrumenting-implants. This subject has been a controversy for a long time on social media and even in the literature.
Some past recommendations have been plastic, titanium, gold, magnetostrictive inserts with a plastic cover, or piezoelectric coated tips.
For the most part, we were taught that plastic is safe on dental implants; it's plastic, after all. As clinicians, we know it can remove food particles, but what about sticky plaque, biofilm, or even calculus and cement? We also know plastic is much softer than titanium and therefore can be abraded by metal.
If we know this, then why would plastic be recommended and used? There is the potential for the plastic particles to break off from the roughness of sliding up and down the dental implant threads and possibly becoming lodged underneath the gingival tissue, which could lead to peri-mucositis. The same can be said for the plastic covers on the ultrasonic tips (ultrasonics and implant instrumentation will be saved for a separate article).
The gold standard for instrumentation of titanium dental implants is titanium, or more accurately, an alloy that is of the same hardness or softer than the material that you are cleaning. Titanium can be heat-treated or not, medically graded or not, and the hardness can vary due to these and other circumstances. About 90% of dental implants have a micro/macro-etched surface, which enhances surface area and promotes osseous-integration.5-7
"Assessment is critical in the model of care and approach to evaluating health and disease in dental implants," said Tracy Butler, CRDH, MFT, the director of hygiene education/relations for Straumann. Tracy's recommendation is "medical grade 4 non-heat-treated titanium" for instrumentation of current dental implants. So, while there is a lot of research on instrumentation or surface abrasion of titanium with various materials, if it is not on the type of titanium in today's dental implants, then it is irrelevant.
There is certain "hardness" to these metals that we want to determine. When discussing hardness, refer to the Rockwell scale of hardness, and also contact an American Eagle educator for their webinar, which explains this in simpler terms.8 (You will also get a CE credit.)
If the information shared within this article has been completely new to you (as it was for me), I would recommend three things:
- Visit Tracy Butler's webinar, "The Implant Is Restored, Now What?" on Colgate's Oral Health Network. She goes into great detail about the maintenance of dental implants.
- Go to American Eagle Instruments website and look at their implant instruments-perfect examples of medical grade 4 non-heat-treated titanium.
- Purchase the book, "Peri-Implant Therapy for the Dental Hygienist," by Susan Wingrove.
Most all of this information was never taught to me in school. We graduate as "safe beginners," as I have heard Shirley Gutkowski, RDH, say. If we continue after college doing the bare minimum, then we will always be "beginners."
Beyond the Fundamentals
I have long since accepted that school taught me the fundamental principles to be able to adapt and practice efficiently as a dental hygienist. The rest was up to me through dedication, desire, improvement, and continuing education.
We need to continue with lifelong learning, focusing on current dental research, to be the best we can be for our patients, and just as importantly, ourselves.
The constant acquisition of new information and knowledge will make an employee much more beneficial and in demand in any practice setting. With the saturation of the job market, it is imperative that we present ourselves as smart, adaptable, and contemporary while always remaining teachable no matter how long we have been in practice.
We are all required to take continuing education and should see the requirement as an opportunity for growth, not an annoying interruption in our day. Additionally, rather than picking a course that is easy, inexpensive, or convenient, choose one that is challenging or completely out of your skill set. Go beyond the minimum requirements. Take the free classes for additional achievements. You can also find, save, load, and check that the classes you take are approved by your state by joining CEZoom (another wonderful company I had the pleasure of meeting at the retreat).
Patients look to dental hygienists for clarity, compassion, truth, and explanation. It is imperative for hygienists to know all parts of the treatment plan for the dental patient. We have the chance to implement life-changing results by practicing to our fullest within our discipline in health care. We also can be a part of an interdisciplinary approach to collaborate with one another through knowledge and compassion for the most optimal outcome of our patients' treatment course.
Are we "just dental hygienists who clean teeth"? Or, are we "dental hygienists who provide patients with optimal oral health through education and understanding, because we are informed in all areas of their treatment needs by constantly seeking to learn more"?
What kind of dental hygienist are you? What is your worth and value? If you do not know, find out by digging deep, asking people who love you or know you best for their input, or what greatness they see in you.
Go to CareerFusion; you will not regret it. If you are completely open to the possibility of discovery, I can guarantee you will never regret your decision to attend CareerFusion. Full disclosure: If you know exactly who you are, you are exactly where you want to be and doing exactly what you love doing and would not change a thing in your career or even life, well then I can't guarantee you anything from CareerFusion, except friends for forever! The time to invest in you is now because no one else will. RDH
Links to manufacturers or websites mentioned in article:
1. American Eagle Instruments: am-eagle.com/products/implant-instruments
2. American Eagle webinar: am-eagle.com/education/clinical-educators
3. CareerFusion: careerfusion.us/careerfusion-discovery-1.html
4. CEZoom: cezoom.com
5. Colgate webinar by Tracy Butler: colgateoralhealthnetwork.com/webinar/the-implant-is-restored-now-what/
6. Straumann: straumann.us/en/professionals.html
Elicia Lupoli, RDH, BSDH, graduated from University of Bridgeport, Fones School of Dental Hygiene, in 2002. In 2012, she went back to Fones to complete her bachelor's degree in dental hygiene. She advocates for whole-body health in all her endeavors. Elicia is a CareerFusion 2016 member and credits the start of her professional writing to Shirley Gutkowski, RDH, BSDH, for inspiration and continuous mentoring. She can be reached at [email protected].
References
1. Christensen G. Products rated highly by evaluators in CR clinical trials. Clinicians Report. 2015;8(9):1-3. doi://us.guidor.com/cliniciansreport
2. Lang NP, Kinane DF, Lindhe J, Sanz M, Tonetti MS. Sixth European Workshop on Periodontology of the European Academy of Periodontology at the Charterhouse at Ittingen, Thurgau, Switzerland. Journal of Clinical Periodontology. 2008;35:1-2. doi:10.1111/j.1600-051X.2008.01255.x
3. Wingrove S. Peri-Implant Therapy for the Dental Hygienist: Clinical Guide to Maintenance and Disease Complications. Wiley-Blackwell 8:2013.
4. U.S. Department of Health and Human Services, Food and Drug Administration, FDA Approved Drugs Products. doi://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails
5. Academy of Osseointegration. Advancing the vision of implant dentistry. 2016. doi://www.osseo.org/
6. Gaviria L, Salcido JP, Guda T, Ong JL. Current trends in dental implants. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2014;40(2):50-60. doi:10.5125/jkaoms.2014.40.2.50
7. Gupta A, Dhanraj M, Sivagami G. Status of surface treatment in endosseous implant: A literary overview. Indian J Dent Res. 2010;21:433-8. doi:http://www.ijdr.in/text.asp?2010/21/3/433/70805.
8. Fuller A. The science behind instrument selection: The Rockwell scale is the key to evidence-based instrument selection for dental implant maintenance. Dental Products Report. 2015. doi://www.dentalproductsreport.com/dental/article/science-behind-instrument-selection?page=0,0
