by Ann-Marie C. DePalma, RDH, BS
When I present continuing education programs on dental implants for members of the dental team, hygienists have many questions about the whole implant process. As hygienists, how can we effectively interest our patients in the pros and cons of a procedure without understanding the process ourselves? Implants are now considered the standard of care and must be presented to patients, in addition to traditional methods, as part of the overall treatment plan for restoring edentulous areas. Many hygienists have questions about what types of maintenance procedures can and cannot be done for implant patients. So I have come up with a list of the most frequently asked questions (FAQs) concerning implants.
"I know I can't use metal curettes on implants, but the scalers we have in our office just don't cut it. What should I do?"
It is true that stainless steel curettes should not be used on implants. The titanium metal is easily scratched by stainless steel, which could result in more plaque and calculus accumulation. However, the plaque and calculus that forms on most implants is of a different consistency than on teeth. It is much more readily removed and, therefore, responds differently to scaling. Using a variety of the newer types of implant scalers that are available (graphite, resin, or plastic instruments made by Hu-Friedy, AIT Dental, Steri-Oss, or Premier) is usually sufficient. Having a variety of plastic instruments on hand is advisable; in that way, you can be prepared for whatever comes your way.
In addition, if the scaler can be sharpened, use only a dedicated sharpening stone on the plastic scaler. A stone that is also used on stainless steel can have flecks of metal imbedded in it, which, theoretically, can be transferred to the plastic instrument and then onto the implant, thereby scratching it.
"Can I use ultrasonics (either piezo or magnetostrictive) on implants?"
Ultrasonics should not be used on implants, since the metal tips can scratch the softer titanium. However, there are plastic sleeve covers that can be placed on the tips to reduce the possibility of scratching.
In addition, there are specifically designed plastic scaler tips that may be purchased. However, these tips are only useful on specific ultrasonic systems.
Most often, though, the use of ultrasonics on implants is not warranted. As mentioned previously, the amount and tenacity of calculus found on implants is less than on the natural dentition.
Regardless, there are times when ultrasonics may be indicated. If a patient has had an implant scratched during a previous maintenance visit, there may be heavier than expected deposits present. Gouges made by stainless steel curettes on titanium implants can cause more plaque and calculus buildup to occur on the implant. Over a period of time, this buildup causes a vicious cycle of buildup needing heavier instrumentation that, in turn, causes more gouging — one reason hygienists should be fully aware of the techniques and instrumentation used for implants.
With the advent of implant prosthetics resembling more traditional crown-and-bridge restorations, it is often impossible to recognize what is an implant-supported prosthesis vs. a traditional prosthesis. The hygienist needs to be aware of the presence of implants and decide which instrumentation is best for that particular implant system and prosthetics.
"Do you probe implants?"
Many controversies surround implantology. Dental professionals are only beginning to understand issues such as surgical sterility, attachment apparatus, and probing. It is so important for hygienists to be continually updated about implants. There are a variety of opinions regarding whether implants should be probed, but all agree that they should only be probed with plastic probes.
Probing, while using pressure-sensitive probes (or only using about 20 grams of pressure) is considered safe around implants. This light pressure is needed to avoid damage to the delicate fibers that surround the implant.
One previous recommendation on probing was to probe initially at the time of the first restorative maintenance visit and thereafter only if problems arose. However, a current recommendation is to probe initially, and then yearly, but only on the buccal and lingual surfaces. Radiographs can be taken to see the mesial and distal aspects of the implants. But since radiographs are a two-dimensional view of a three-dimensional area, the buccal and lingual areas are indistinguishable.
Probing once a year can reveal any problems that could lead to loss of osseointegration. However, prior to each measurement, the probe should be dipped into chlorhexidine solution to prevent bacterial cross-contamination. Depending on the type of abutment present — either straight or angled — the depth of the perimucosal seal may be two to three millimeters, or as much as five millimeters, but still healthy. The hygienist needs to know baseline measurements, to be able to distinguish health from disease, or loss of osseointegration.
"What types of home-care techniques can I use for an implant patient?"
The same basic home-care regimens that are followed for periodontal patients can be used for implant patients, with a few minor alterations. Whatever toothbrush is effective for a patient is the one that should be recommended, whether it is sonic, electric, or manual. The same is true with flossing; there are a variety of flosses available for patients. Whichever one the patient is most comfortable with is the one that will be used with compliance.
Interdental brushes can also be recommended; however, only nylon and not wire-coated is advised. The same goes for any subgingival irrigation recommendations; only plastic-coated tips should be used. Hallmarks of good home care, whether for implant patients or regular maintenance patients, include setting a regimen for the patient to follow remains based on individual needs, allowing the patient to demonstrate techniques, and reinforcing these at each visit.
"Why are implants so expensive?"
The actual implant parts, manufactured by the dental implant companies, are a relatively minor portion of the total cost of implant therapy. It is the prep time — the dentist's chair and non-chair time — that encompasses the majority of the cost for implants. However, in the long run, when compared to partials or bridges, the average cost is equivalent. Bridges and partials eventually need replacement; implants usually do not. Dental insurance companies are beginning to recognize that implant dentistry is a viable alternative to traditional dentistry in the cost to benefit ratio. It will be interesting to see how the insurers respond to the new CDT-4 codes that became effective in 2003 and what benefits will be allowed for implant therapy.
I hope this brief introduction into the world of dental implants has given you some "food for thought." Dental hygienists need to be aware of how dental implantology is a rapidly growing and changing field. We must educate ourselves about the best ways to manage our dental implant patients. You currently may not be seeing a lot of implant patients, but, within the next several years, you will! Implantology is a field whose time has come.
Author's note: Information for this article was taken from the Association of Dental Implant
Ann-Marie C. DePalma, RDH, BS is a practicing hygienist in a periodontal-implant practice.She is a graduate of the Forsyth School for Dental Hygienists and is a Fellow of the Association of Dental Implant Auxilliaries and Practice Management.Ann-Marie has written articles and presents programs on dental implants, TMD, and developmental delays.