The Whos who of implant candidates

Numerous articles have considered the role of the hygienist in the care and maintenance of dental implants. However, none have dealt with the role the hygienist can play in the selection of patients for implants. As more patients are seek implant therapy, we need to do a better job of assessing what types of patients are good candidates for implants and what types are not. Dental implants rank second only to bleaching procedures as the most asked-about topic in dentistry by the general public. I

Oct 1st, 1998

The hygienist can assess which patients would benefit from implant therapy.

Ann-Marie C. DePalma, RDH, BS

Numerous articles have considered the role of the hygienist in the care and maintenance of dental implants. However, none have dealt with the role the hygienist can play in the selection of patients for implants. As more patients are seek implant therapy, we need to do a better job of assessing what types of patients are good candidates for implants and what types are not. Dental implants rank second only to bleaching procedures as the most asked-about topic in dentistry by the general public. It behooves the hygienist to be aware of the potential candidates for implants and provide the staff with another avenue for enhancement of the dental practice.

The National Institute of Dental Research determined in a national survey that 20 million Americans are edentulous. The population aged 65 and over, which is a growing segment of the general population, averages approximately 10 missing teeth. If so many are either completely or partially edentulous, what are they replacing their dentitions with? Many have removable partials or complete dentures. The NIDR survey also calculated, though, that 50 percent of those with full dentures don`t wear them and those with partials are not satisfied with them. The reasons for this are numerous. A whole industry has grown out of the need for more esthetics and comfort in denture wear. At the same time, an explosion of knowledge in the implant field has allowed the growth and success rate of implants to reach over two million implants placed and retained by 1998. If so many implants are being placed, how do you select which patients may be good candidates for implantology and which may not? This article will help the hygienist in the selection process.

Implantology has grown within the last several years to involve an art and science of varying degrees. Implants can be used to replace single teeth, such as a several-unit bridge or as a support (either fixed or removable) for a full denture. To communicate the reasons a patient may need or want implants, one must understand the value of implants for the patient. Implants help improve function, esthetics, phonetics, and the health/digestion of patients. If fully edentulous patients have lost a lot of vertical dimension and have a difficult time chewing their food, their health may be compromised due to poor nutrition. They may experience muscle pain and a general overall feeling of "unwellness." Implants can restore the physical and emotional health of these patients. However, implant therapy can be a long process, taking anywhere from six months to several years to complete. Patients undergoing implants must be aware of the time, financial, and maintenance commitments involved in their treatment.

Anyone, with a few exceptions, can be a general candidate for implants. Any edentulous area is a potential implant site. Patients can be asked about their interest in implants as part of the general dental/medical history and exam. Many patients will say they are not interested. Others may have questions or concerns. It is in these patients that the "seeds" about implants can be placed.

Several medical and dental conditions can reduce a patient`s success in the implant process. Medical conditions such as HIV and other immunocompromised states, uncontrolled diabetes, diseases of bone metabolism, heavy smoking, and alcoholism can disqualify patients for implants. HIV and other immunocompromised patients must be taken on an individual basis.

Some HIV patients are willing to try implant therapy to improve digestion. However, these patients must be well-controlled and on strict medical protocols. Patients who are in active treatment and those whose life expectancies are short are not ideal candidates. The primary reason for this is that these individuals develop infections at a higher rate than others do, which can be detrimental to the success of the implant.

Uncontrolled diabetic patients also are not good candidates since they have poor vascularization of gingival tissues, along with a slower healing process and a higher risk of infection.

Heavy smokers are contraindicated for implant placement since they have poor vascularization of tissues, as well as the general chemical irritants caused by the tobacco and smoke. Patients who are nonsmokers tend to have a better overall success rate with implants than do smokers.

Because alcoholics tend not to value themselves or their health status, implants are contraindicated. An alcoholic is defined as a person who drinks three or more alcoholic drinks each day. Often, they tend to be malnourished and have a vitamin B deficiency, which can retard wound healing. Since implant placement and success depends on the body`s ability to osseointegrate the implant into the bone, then any disease which affects the ability of the osteoblasts to lay bone - or to aid in wound healing of bony tissue - is a detriment to the placement of implants.

Age, osteoporosis, and periodontal bone loss may appear to prohibit implants, but they do not. A person who is in relatively good health can undergo elective surgical procedures. If patients are aware of the time and financial commitments of implants, they can be selected for implant placement. There is no "cut-off" age for implants. However, children younger than 16 years, who still are undergoing growth spurts, are not potential candidates because of the rapid changes occurring in their bodies.

Osteoporosis is not a medical contraindication since diet and medication can control it. If it does affect the jaws, the process of progressive loading of an implant can actually increase the bone density around the implant (progressive loading is the gradual application of occlusal forces on the implant and restoration using temporaries in acrylic or through denture soft relines).

All potential patients, with the exception of trauma patients, have some degree of bone loss, or they wouldn`t need implants! However, patients who are undergoing active periodontal therapy with active attachment loss, are not ideal candidates, since the same bacteria that can affect teeth can be detrimental to the health of an implant. On the other hand, periodontal maintenance patients who are compliant with home care are excellent implant patients.

Specific types of dental patients can be acceptable or unacceptable candidates for implant surgery. Not only are implant contraindicated for active periodontal patients, they also are contraindicated for those who have demonstrated an unwillingness or inability to maintain hygiene. These patients may include noncompliant periodontal patients, physically disabled (individual consideration needed), and dental phobics.

Patients who have unrealistic expectations as to what implants can or cannot do for them also often are unacceptable candidates. Whenever a patient comments, "I want to get rid of my teeth and not have to come back here again" or "I want to revive my youthful-looking appearance," beware! Implants are maintenance-intensive for both the patient and the clinician. Patients are seen by the surgeon and the restorative dentist for the initial workups, surgical series and follow-ups, and needed restorative care. Following the completion of implant placement, patients should be seen on a regular three- to four-month recall schedule to access the implant and surrounding dentition. A completely edentulous patient can be seen on a six- to 12-month recall program for evaluation.

If the patient appears to be a candidate for implants, further investigative diagnostic procedures can be performed. These include clinical and radiographic exams, along with study models, and computed tomographies (CT`s) depending on the case and office philosophy.

Implant dentistry is an exciting field within our profession. Dentistry now has the opportunity to assist patients who previously may have been unsatisfied with conventional dentistry. Implants are not for all patients. But the hygienist can aid in the selection process of patients to improve the overall success rate of implants.

Ann-Marie C. DePalma, RDH, BS, is a 1978 graduate of the Forsyth School for Dental Hygienists. Ann-Marie is active in the Massa-chusetts Dental Hygienists` Assoc-iation, having served in various positions, and is also a past president of the Forsyth Alumni Assoc-iation. Ann-Marie is currently em-ployed as a clinical dental hygienist in a periodontal/implant practice. She is a certified instructor in the Dental Hygiene Implant Cer-tification Program of the Assoc-iation of Dental Implant Auxiliaries and Practice Management (a component of the International Con-gress of Oral Implantologists). She is also an educational consultant for 3i-Implant Innovations.

Resources:

- Association of Dental Implant Auxiliaries and Practice Management`s Dental Hygiene Implant Certification Program

- Contemporary Implant Dentistry, Carl Misch, DDS, Mosby Publishers, 1993

- 3i Implant Innovations Dental Hygiene Continuing Education Programs

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