Implant maintenance and the dental hygienist by liwenting

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and the
dental hygienist
supplement to
may-june 2003
2      Introduction

2      The Role of the Registered Dental Hygienist

3      History of Implants

4      Types of Implants

4      Client Assessment

6      Treatment Planning

6      Surgical Placement of the Implant

7      Restoration of the Implant

8      Mucogingival Tissues

8      Baseline Data

9      Maintenance

10     Ailing/Failing Implants

10     Summary

11     References

     About the Author                            This supplement to
                                                 Access magazine was
     Sheri Granier Sison, RDH, BS, is clinical   sponsored by AIT Dental,
     instructor and faculty co-supervisor of     Hu-Friedy Manufacturing Co.,
     the Implant Clinic at the Louisiana State   and Oral-B Laboratories.
     University Health Sciences Center
     School of Dentistry.

                                                       Access—special supplemental issue 1
Introduction                                implant dentistry allows the dental        bone, surgical procedures such as guid-
                                            hygienist to function in many of the       ed bone regeneration, bone grafts, or
      Edentulousness is on the decline,     stages of dental implant therapy and       bone substitutes may be considered.21,22
but it will increase dramatically in the    help the therapist perform a great serv-   A client who meets these criteria
adult population older than 55 years.       ice to the client who requires prostho-    should be educated about implant den-
One study suggests that despite the         dontic treatment. This supplement dis-     tistry and further evaluated as an
10% decline in tooth loss in each of the    cusses the indications for dental          implant candidate.
last three decades, the 79% increase in     implants, maintenance and monitoring            According to Terraccino-Mortilla,
the senior population will result in        of implants, and the role of the dental    the dental hygienist should develop
37.9 million adults requiring one or        hygienist in successful implant-based      client-specific home care routine for
two complete dentures in 2020.1 The         prosthetic treatment.                      the implant client.13 This is a dynamic
prevalence in tooth loss in the United                                                 process, because home care must be
States for adults 18 years or older is                                                 altered with each stage of the dental
9.7% and increases to 33.1% at 65 years    The Role of the                             implant       including      post-surgical
or older.2 Missing teeth can cause loss    Registered Dental                           hygiene, provisional restoration, and
of self-esteem and have an impact on       Hygienist                                   final restoration or prosthodontic deliv-
social interaction.3 The diminished                                                    ery. In the delivery of oral hygiene
masticatory efficiency accompanying             Terracciano-Mortilla suggests that     instruction, the dental hygienist should
tooth loss can compromise nutritional      the dental hygienist perform a variety      also provide client motivation. Tissue
status, putting clients at higher risk for of duties as a member of the implant        destruction in the periimplant site is
chronic illnesses like diabetes, cancer,   team.13 One of the initial duties is the    prevented by the absence of bacterial
hypertension, and heart disease.           identification and education of poten-      plaque, and the client must participate
      Conventional dentures typically      tial implant candidates. The success of     in primary preventive measures.23-28
attain only limited success with respect   the implant relies heavily on the health    Compliant clients are ideal candidates,
to both client satisfaction and chewing    of the implant environment. Control of      since implants are maintenance inten-
ability. An implant-retained prosthesis    bacterial plaque through home care has      sive. Noncompliant clients need to be
provides greater stability, improved bit-  been related to periimplant bone loss.14    fully educated and thoroughly trained
ing and chewing forces, and higher         Implants should not be placed in the        before implant therapy begins.29
client satisfaction than a conventional    client who cannot demonstrate an            Behavior modification is essential in
denture.5-11 Dental implants also may be   effective home-care regimen.15 An           these situations. The client should be
used to replace teeth in a client who is   implant candidate must understand and       discouraged from becoming compla-
partially edentulous. Osseointegration     accept the time and financial commit-       cent with home care and understand
provides support for function, while       ment that the procedures require. The       the importance of plaque control and
dental implants are used as replace-       dental hygienist should also be aware of    tissue health. Clients that lost their teeth
ments for natural teeth. Technological     the client’s overall health history.There   due to poor self-care can easily return
advances have allowed for the increased    should be minimal risk to the client        to previous neglectful behaviors.30
acceptance and use                                              undergoing surgery,         The maintenance appointment
of dental implants         An implant-retained and the client                          allows the dental hygienist to partici-
in a variety of res-                                            should be free of      pate in many aspects of implant treat-
torative treatments.        prosthesis provides any systemic illness-                  ment. Assessment of tissue health can
      The       dental        greater stability,                es or other factors    allow for early intervention in the dis-
hygienist is involved                                           that may delay heal-   ease process. Although the soft tissue
in all facets of client    improved biting and ing.16-19 Finally, the                  surrounding the implant is similar to
care, the consistency      chewing forces, and client must have                        the environment of a natural tooth, the
of which leads to                                               adequate bone in       periimplant connective tissue is more
enhanced relation-               higher client                  which to place the     vulnerable to infection due to
ships. Combined              satisfaction than a                implant. An ideal      decreased vascularity and lack of true
with maintenance                                                radiographic assess-   connective attachment.15,31–34 Clinical
skills, strong client/ conventional denture. ment of bone dis-                         assessment includes determining the
caregiver bonds allow                                           plays quantity of      presence or absence of bacterial plaque,
the dental hygienist to function as a      bone in three dimensions, anatomical        bleeding on probing, and exudate.32,35,36
vital member of the dental implant         landmarks, and the quality of available     Investigators are sharply divided on the
team.12 A comprehensive knowledge of       bone.20 For clients with inadequate         issue of periodontal probing in the

2 special supplemental issue—Access
implant environment. It has been sug-                 According to Terraccino-Mortilla,    Radiographs showed compact bone
gested that probing of the implant sul-         the dental hygienist should document       formation around three tooth-shaped
cus is not truly diagnostic and can be          all findings.13 Documenting of baseline    pieces of shell implanted in sockets of
detrimental to the delicate attach-             data is important, as changes can be an    missing lower incisors, similar to the
ment.15,33,36,37 It also has been suggested     early predictor of impending problems.     bone surrounding a modern blade
that probing is indicated only in               Baseline data should include the pros-     implant.43
implants where pathology such as                thesis design, hard and soft tissue eval-        Innovations in dentistry dwindled
bleeding and exudate is present.32,38           uation, occlusion, radi-                                     following the fall of the
Tissue health is a strong predictor of          ographs, implant mobil-                                      Roman Empire, but
the long-term success of the dental             ity, and procedures per-       Early Etruscans they were revived dur-
implant. Assessment of the implant soft         formed to maintain the replaced missing ing the Renaissance. By
tissue should be accompanied by a               implant. Oral hygiene                                        the 1800s, fixed bridges
radiographic examination of the hard            status and the client’s            teeth with                and partial dentures
tissue surrounding the implant.                 responses and attitudes          artificial teeth            were successful meth-
Radiographs should be evaluated for             should be documented.                                        ods of tooth replace-
the presence of radiolucencies and              Management of data             carved from the ment. In 1885, Dr. J.M.
excessive bone loss.15,32,33,36,37,39,40        can be accomplished by          bones of oxen. Younger implanted a
     During the maintenance appoint-            use of a special form                                        natural human tooth
ment, the dental hygienist should               that follows the course                                      into an artificial socket.
remove deposits of any nature, includ-          of the implant from baseline data col-     Younger’s procedure included filling the
ing soft plaque and calculus.                   lection.42 Finally, the dentist should be  pulp chamber of the tooth with gutta
Debridement is accomplished with                informed of the status of the implant so   percha and the apical opening with
implant-safe instruments. Plastic,              that problems can be addressed expedi-     gold. A tooth from any source was
graphite, and gold-tipped instruments           tiously.13                                 acceptable, according to Younger, pro-
can be used to remove deposits with-                                                       vided that asepsis was maintained.
out damaging the implant surface                                                           Although his work was largely unsuc-
(Figures 1-3). An ultrasonic tip may be         History of Implants                        cessful, it spurred many later attempts
used only with a plastic covering that                                                     at implantation. Technical advances
prevents gouging and disturbance of                   The dental implant has a lengthy     include implanted tubes of gold and
the titanium surface. Polishing the visi-       history, beginning with ancient            iridium, lead and porcelain posts, and
ble portion of the implant can be               Egyptians, who implanted teeth in          bovine incisor teeth into natural or
accomplished with rubber cups and               corpses in accordance with religious       artificially created sockets.43
nonabrasive polishing paste or tin              beliefs regarding the afterlife. Accord-         In 1948, two American dentists,
oxide.15,32,39-41 In the first year following   ing to evidence discovered in under-       Gershoff and Goldberg, surgically
restoration of the implant, the client          ground burial chambers in what is now      placed a subperiosteal implant created
should be evaluated every three                 modern Italy, early Etruscans replaced     by Dr. Gustav Dahl of Sweden. The
months. The dental hygienist should             missing teeth with artificial teeth        subperiosteal implant was prefabricated
take oral hygiene, tissue health, and           carved from the bones of oxen. The         based on a study model. This method
amount of deposits into consideration           Romans conquered the Etruscans and         of implantation met with limited suc-
to determine a client-specific recall           employed their dental techniques until     cess and proved over time to have a
system after the initial 12-month peri-         the fall of Rome. The earliest             high failure rate due to infection.43 In
od. A four- to six-month recare system          endosseous implant was discovered in a     1965, Swedish orthopedist P. I.
should be used dependent on the indi-           mandible fragment of Mayan origin          Brånemark placed the first titanium
vidual factors.15,32                            dating from about A.D. 600.                implant and coined the term “osseoin-

Figure 1. Plastic scaler.                       Figure 2. Graphite scaler.                   Figure 3. Gold-tipped scaler.

                                                                                        Access—special supplemental issue 3
tegration.”44 Osseointegration—incor-      the TMI system. TMI is more invasive             The first consideration is the
poration of the implant with the           than other implants and usually             client’s medical history.Vital signs such
bone—is one of the greatest achieve-       requires hospitalization. Scientific liter- as blood pressure, pulse, and respiration
ments in implant dentistry. In 1967, Dr.   ature indicates success with this system,   should be assessed and documented to
Leonard Linkow of New York City            although it is very demanding for the       determine if the client is capable of
placed the first blade implant, and by     client and the practitioner.49              undergoing surgery requiring anes-
the 1970s, this was the most frequently         Blade or plate-form implants are       thetic and pain-controlling medica-
employed implant design.44                 also considered endosteal implants.         tions. Basic lab work such as blood
                                           Blades, successfully used in a variety of   count, urinalysis, or sequential multiple
                                           bone widths and heights, can be placed      analyzer of the blood chemistry
Types of Implants                          anywhere in the mandible or maxilla         (SMAC) can assist in ruling out sys-
                                           with sufficient bone.They can be placed     temic complications.16,57
     A subperiosteal implant is not        when a client does not have adequate             To be considered for implants, the
placed within alveolar bone, but under     bone for a cylindrical implant and are      client should be categorized as to clas-
the periosteum, against the bone. This     appropriate for most implant candidates.    sification of presurgical risk, as set forth
type of implant is custom-made from a      Blade implants have been used with suc-     by the American Society of
direct bone impression. This requires      cess for the last 30 years.50,51            Anesthesiology.57,58 Class I includes the
two surgeries—the first for fabrication         Similar to the shape of a natural      client with no systemic illnesses and a
and the second for implant placement.      tooth root, root-form implants can be       normal lifestyle. Clients with well-con-
The subperiosteal implant is rarely        placed in the mandible or maxilla with      trolled systemic illnesses who are able
indicated except for severely resorbed     adequate bone. This endosteal implant       to engage in normal daily activity are
edentulous areas.45 Atrophic changes in    can also be placed in one or two            categorized as Class II. Clients in class-
the edentulous jaw are common, caus-       stages.45 Although root-forms require       es I and II are usually considered
ing implant mobility and decreased sta-    osseointegration achieved in a two-         implant candidates. A client with
bility, and facilitating infection.46      stage procedure, no                                              impaired activity
Subperiosteal implants are rarely seen     significant differ-                                              because of a chronic
today because they were commonly           ences in the success        To be considered for condition or mul-
removed due to complications. The          of one-stage or              implants, the client                tiple medical prob-
client with the subperiosteal implant      two-stage insertion                                              lems falls into Class
must be continuously monitored and         are noted in the lit- should be categorized III, and may be a
the implant must be removed upon           erature.52-56     The      as to classification of candidate for im-
infection to prevent extensive damage      root-form implant                                                plants but will
to the alveolus.47,48                      has been studied presurgical risk, as set require certain meas-
     Endosteal implants have proven        more than any forth by the American ures prior to sur-
successful in single-tooth replacement     other implant form.                                              gery to stabilize
as well as in the edentulous arch. One     It has consistently                 Society of                   systemic problems.
or two surgical interventions may be       proved safe and effi-            Anesthesiology.                 Clients in classes
required for placement. One-stage          cacious in the sup-                                              IV and V have seri-
implants are placed in a single surgery,   port of prosthodon-                                              ous medical condi-
and a healing collar is placed at or       tic restoration.45                          tions and are not appropriate implant
above the gingiva. This eliminates a                                                   candidates.57,58
second surgical procedure to expose                                                         Clients who have chronic illnesses
the implant, as completes the two-stage    Client Assessment                           that could compromise healing should
procedure where the implant is com-                                                    not have implants placed. Bleeding dis-
pletely submerged under the gingiva at          Initial assessment of an implant       orders, connective tissue disorders,
insertion.45                               candidate should include a thorough         chronic steroid therapy, and immuno-
     Transosteal or transmandibular        medical, dental, and psychological eval-    suppression therapy can hinder healing
implant (TMI) reconstruction systems       uation. To ensure success of the            and therefore osseointegration. Clients
are indicated only for the severely        implant, the client must be in good oral    who have well-controlled diabetes have
resorbed mandible.They are an invasive     and physical health. Because the            shown no higher incidence in implant
and technique-sensitive form of            implant is maintenance intensive, the       failure; however, an uncontrolled plas-
endosteal implants. Bone loss is stopped   implant client must also be prepared to     ma glucose level can have a negative
and bone growth may be induced by          maintain the health of the restoration.     effect on the healing potential of the

4 special supplemental issue—Access
implant, so that is a contraindication      and/or neglect.62 The client who is       alveolar canal that can affect the suit-
for implant treatment.59,60 Tobacco use     typically noncompliant will require       ability of the implant; also, panoramic
has also been statistically associated      thorough education and should             radiographs can adequately depict
with implant failure. The clinician         demonstrate compliance and a com-         bone height. Like the periapical X-ray,
should address the impact smoking has       mitment to home-care and mainte-          it is inadequate for the examination of
on implant survival and may choose          nance visits before implant therapy is    bone width, but is commonly
not to place implants in smokers.61         initiated.15                              employed in initial treatment planning
     Psychological evaluation of the              The client who became fully         or screening.20,64
implant candidate includes intangible       edentulous as a result of periodontal           Digital radiography is rapidly
factors that affect the outcome of the      pathogens is at no greater risk for peri- evolving and has shown tremendous
restoration.The client must have realis-    implantitis due to periodontal            potential in generating images in
tic expectations of the restoration in      pathogens. A liter-                                            panoramic and
regard to its usefulness and aesthetic      ature review by                                                periapical films.
value.The practitioner should take into     Quirynen et al.
account the needs and desires of the        indicates that, a
                                                                    The client who became Occlusal be used graphs can

implant candidate, and fully inform the     month after dental        fully edentulous as a only to evaluate
client how these will be met.57 The         extraction, certain
types of procedures expected, as well as    known periodon-
                                                                      result of periodontal the mandibular sym-
                                                                                                           physis, so they are
the expected impact of transitional         tal pathogens can           pathogens is at no                 limited in their
restorations, should be disclosed to the    no longer be de-                                               applicability. The
client. The client also should have a       tected.63 The levels
                                                                           greater risk for                relationship of the
realistic concept of the time commit-       of pathogens remain      periimplantitis due to maxilla, mandible,
ment required. He or she should be          barely detectable
fully apprised that implant placement       after replacement
                                                                    periodontal pathogens. and skullevaluation
                                                                                                                     base may

and restoration involves a number of        of the teeth by                                                in certain cases
stages and need ample time for healing      implant-supported                                              such as the com-
and osseointegration.                       prostheses. There also is a strong simi-  pletely edentulous client or the client
     With respect to the cost of            larity in subgingival plaque composi-     who may require orthognathic correc-
implants, the client should be aware        tion in implants and teeth in the par-    tion. The lateral cephalometric radi-
that the financial commitment includes      tially edentulous clients. A tooth with   ograph may be indicated in these
paying not only the implant place-          advanced periodontitis can act as a       cases.64
ment, ancillary procedures, and restora-    reservoir for periodontal pathogens;            Computer axial tomography (CT)
tion fees; but also the required ongoing    therefore, partially edentulous clients   enhanced with special dental process-
maintenance costs. Maintenance              are at greater risk for periimplanti-     ing programs provides the greatest
requires three-month visits and radi-       tis.41,63 This promotes the notion that a detail with panoramic, cross-sectional,
ographs in the first year following         good implant candidate is one who is      and three dimensional views of the
restoration and four- to six-month          etiology-controlled and free from den-    mandible or maxilla. The CT scan can
recare afterward.32,40 There also may be    tal diseases.15                           predict bone volume and density as
a need to replace devices used to inte-           Dental evaluation of the implant    well as the accurate position of
grate the implant and the prosthesis.       candidate must include a thorough         anatomical landmarks; however, cost,
The client must have the ability to         radiographic examination to allow         access, and radiation exposure must be
maintain oral hygiene throughout            evaluation of the alveolar bone. By       weighted against the advantages before
treatment to protect the healing            considering the anatomy of the            the client undergoes a CT scan.20,64
implant site from pathogenic bacteria.      implant site, the practitioner can deter-       The oral examination should take
     A thorough dental evaluation           mine the prescribed radiographs. A        radiographic determinants into account.
should be performed that includes           periapical radiograph shows the loca-     The client must have adequate bone
questioning the client regarding dental     tion of tooth roots and opaque foreign    width and height for placement and
history. Identification of the cause of     bodies that can affect the implant site.  osseointegration of the implant.
the client’s tooth loss is imperative.The   However, it does not indicate bone        Positioning of the implant is key and
client who lost teeth as the result of      width and so is limited in this indica-   the partially edentulous client must
trauma or an accident will likely be        tion. Panoramic radiographs can be        have adequate spacing.The client’s gin-
more compliant in home-care than the        used to locate anatomical landmarks       gival tissues should be examined for
client who lost teeth due to disease        such as the maxillary sinus or inferior   adequacy and health.57

                                                                                  Access—special supplemental issue 5
                                                  Treatment Planning                             the restoration. Fees and methods of
                                                                                                 payment should be reviewed and
                                                        Joint treatment planning for             agreed upon beforehand, and a written
                                                  implant procedures can begin when              consent should be signed by the client
                                                  oral health is achieved; home care is          for both surgical and restorative treat-
                                                  effective; and the client is fully educat-     ment.57
                                                  ed as to costs, implications, and treat-
                                                  ment options.The key to success in this
Figure 4. Soft bristle brush.
                                                  stage is effective communication               Surgical Placement of
                                                  between the involved parties. The              the Implant
                                                  restorative dentist should have a con-
                                                  ference with the surgeon who will be                 Throughout all phases of implant
                                                  placing the implants. Specialists who          treatment, the dental hygienist func-
                                                  may be providing ancillary treatment,          tions in the primary prevention of dis-
                                                  the dental hygienist, and the laboratory       ease at the implant site. The dental
                                                  technician also may be included.               hygienist must make home-care modi-
                                                  Considerations for the dental team             fications and provide reinforcement to
                                                  should include the client’s medical,           the client at each stage. Following the
                                                  dental, and psychological status.              initial placement of the implant or the
                                                  Providers delivering preliminary treat-        first stage of treatment, the client must
Figure 5. Example of a power toothbrush with      ment such as periodontal therapy,              be advised of the need for gentle but
multiple brush tips that allows complete access   extractions, or orthodontics can inform        thorough home care. Sutures and client
around an abutment.                               the dental team of client progress.            avoidance of the surgical site should be
                                                  Throughout early treatment or team             addressed as mismanagement of them
                                                  discussions, the client’s unsuitability as a   can lead to retention of plaque at the
                                                  candidate for implant treatment may be         implant site.13 Vertical crestal bone
                                                  discovered. At this point, alternate           defects have been noted in one-stage
                                                  treatment plans including fixed bridge-        surgery in the absence of plaque control
                                                  work and partial or complete dentures          in this initial healing period.15,65 The
                                                  should be presented to the client.57           client should be instructed to rinse with
                                                        The implant team should be               chlorhexidine gluconate or apply it
                                                  mindful of the client’s needs and desires      with a swab or tufted brush twice daily.
                                                  and work in cooperation to provide             The substantivity of chlorhexidine
                                                  optimal restoration.The restoring den-         combined with its antibacterial proper-
Figure 6.Yarn.                                    tist should create a definitive treatment      ties can assist in plaque control.15,66
                                                  plan for the client.A diagnostic wax-up              This gentle debridement is effec-
                                                  should be made in anticipation of the          tive only in the initial healing phase
                                                  final restoration. This will allow the         and a new home care regimen should
                                                  dentist to consider spatial relationships      be introduced subsequently to include
                                                  and the alignment of the implants in           a soft toothbrush. Single-tooth restora-
                                                  the context of the existing teeth.             tions can be managed with a soft
                                                  Working with the surgeon to fabricate          toothbrush and floss. Clients who have
                                                  a surgical template, the dentist can help      provisional restorations also should be
                                                  achieve proper alignment and place-            instructed in home care. Several
                                                  ment of the implant.57                         devices can facilitate access to a fixed
Figure 7.Tufted floss.                                  The client should be fully aware of      restoration, including an interdental
                                                  how treatment will proceed. His or her         brush, end-tuft brush, or an interprox-
     Hard-tissue and soft-tissue assessment       obligation to maintenance of the               imal oral health aid. Superfloss or floss
should include mounted study casts.The            implant, including home care and den-          threaders also can remove plaque from
client may require preliminary treat-             tal visits, should be outlined.The prac-       abutment areas. The client should
ment, such as periodontic, orthodontic,           titioner should discuss possible compli-       know where the abutments are and
or restorative treatment, to obtain dental        cations and the client should have real-       how to use oral hygiene aids to clean
health or facilitate implant therapy.57           istic expectations of the outcome of           them.13,15,67

6 special supplemental issue—Access
     At stage-two surgery, the implant      when embrasure space permits (Figure
is exposed and a healing cuff is placed     8).The wire center of the brush should
to promote tissue maturity. The client      be coated with plastic or nylon to pre-
should rinse with chlorhexidine twice       vent scratching of the implant surface.
daily in the 14 days following exposure     An end-tuft brush can access smaller
of the implant, and then implement          spaces and be manipulated under hot
mechanical debridement with a soft          water to accommodate the shape of the
toothbrush or other aid. Chlorhexidine      prosthesis (Figure 9). Foam tips, inter-    Figure 8. Interdental brush for maintenance of
should still be used once a day and         proximal brushes, and disposable            implant-based fixed prosthesis.
should be applied with the same aid         wooden picks are among the many
used for mechanical debridement.15          auxiliary devices that can assist in
                                            plaque removal. Chlorhexidine or anti-
                                            septic rinses can be delivered with
Restoration of the                          these interdental aids to enhance their
Implant                                     effectiveness.68
                                                 Plaque control in a single-tooth
     When the tissue has adequately         replacement is relatively simple. The
matured and the final restoration is        implant abutment is easy to access with
delivered, the dental hygienist should      a toothbrush and the client should be
again modify and reinforce home-care        taught to clean the subgingival portion
principles, considering access to the       of the abutment. Chlorhexidine or
implant, client dexterity, and design of    antiseptic rinses should be delivered by    Figure 9. End-tuft brush.
the final restoration.                      floss daily.Auxiliary aids can be used by
     A soft sulcular toothbrush is the      clients who are unable to floss or have
primary plaque-control device for the       posterior restorations that are difficult
implant abutment (Figure 4). A client       to maintain.68 Adequate oral hygiene is
with limited dexterity should use a         required for all natural teeth to main-
power or sonic toothbrush. Certain          tain health and prevent the emergence
power toothbrushes with multiple            of periodontal pathogens that can rap-
brush tips allow complete access            idly destroy delicate periimplant tis-
around an abutment (Figure 5). Sonic        sue.13,30,48,67                             Figure 10. Calculus buildup around a fixed
and other powered brushes are also safe          A prosthesis that is fixed to the      bridge retained by and implant.
to use around the titanium abut-            implants and is not removed by the
ment.13,15,67,68                            client requires a more detailed home-       hygiene routine to remove materials
     Dental floss can be used to deliver    care regimen. Access to the implants is     that were loosened but not dislodged.68
chlorhexidine to the implant on a daily     often limited by esthetic demands.The            Clients who are able to remove
basis.The use of four-essential-oil rins-   dental hygienist should develop a           their prosthesis have access to the
es twice daily also has been shown to       maintenance plan for the client that        implant abutment, and they may retain
provide benefit to the implant client.69    effectively removes plaque from proxi-      the denture with a bar or a ball attach-
Floss should be inserted at the buccal      mal surfaces. Powered toothbrushes,         ment. It is imperative that these pros-
surface of the implant, threaded around     floss with threaders, and interdental       thetic attachments, as well as the
the lingual aspect, and crossed back to     aids can all be used with fixed-implant     implant abutments, be cleaned as a part
the buccal to completely surround the       prostheses.The delivery of chemother-       of the oral hygiene program.
abutment.67 Gauze strips, yarn, or          apeutics such as chlorhexidine or anti-     Mineralized deposits can build up very
thicker dental floss or dental tape can     septic rinses is especially important       quickly and interfere with the seating
assist with plaque control in wide          because of the decreased access. If         of the denture (Figure 10). A nylon
embrasures (Figures 6 and 7).13,67          brushing or flossing in the lingual         flossing cord is abrasive enough to
     A client who is not able to use        aspect is limited, an oral irrigation       remove calculus and is indicated for the
floss can be instructed in the use of the   device can be used on a low setting.        abutment surface, ball attachment, and
interdental aids. The clinician should      The irrigant should be directed             ridge bar.The bar and ball attachments
consider the embrasure size and shape       through the contacts rather than into       also can be cleaned with a soft-bristle
in the selection of the interdental aid.    the tissue. Irrigation should be per-       brush, end-tuft brush, or interproximal
An interproximal brush is indicated         formed at the completion of the oral        brush. Dental floss, superfloss, gauze, or

                                                                                    Access—special supplemental issue 7
yarn dipped in chlorhexidine or anti-     parallel to the implant surface without             Because the attachment of the
septic rinse should be used around the    true attachment. It also is less vascular      implant is different from that of a nat-
implant abutment. All surfaces of the     and has fewer fibroblasts than in the          ural tooth, the implant is easily com-
prosthesis must be cleaned with a stiff   gingival structures around teeth.32 This       promised by stress. An occlusal evalua-
nylon denture brush daily.                connective tissue attachment forms a           tion is required to assure that there are
     During each visit, the dental        barrier that protects the implant from         no excessive or traumatic stresses on
hygienist should assess the client’s oral bacteria and occlusal forces.The delica-       the implant. Improper contacts, brux-
hygiene and make necessary modifica-      cy of this barrier should be kept in           ism, or other occlusal discrepancies
tions. Home care should be reviewed       mind when probing or scaling the               must be remedied to prevent bone loss.
and reinforced with written instruc-      implant sulcus.                                The prosthesis should have adequate
tion.67 While there                                                                      contacts and embrasure spaces to facil-
is no single oral                                                                        itate home care.13
hygiene aid that          Brushing should be Baseline                                         It has been clearly established that
completely removes                                                                       the periimplant tissue is susceptible to
plaque, the clinician
                        the primary aspect of Data                                       bacterial accumulation and subsequent
should keep in                the oral hygiene                     Immediately fol-      infection. Soft-tissue examination at
mind that compli-                                               lowing delivery of       baseline allows for comparison of peri-
ance is dependent
                                    program. To                 the final restoration,   implant health at subsequent examina-
on the simplicity of                 maximize                   the dental hygienist     tions. The benefit of probing the
the procedure, the
amount of time it
                         compliance, only one should thoroughly document baseline
                                                                                         implant sulcus is a debatable topic,
                                                                                         dependent on the investigator. The cli-
requires, and a min-      auxiliary aid should data. Deviations from                     nician should exercise personal judg-
imal number of oral
hygiene devices.
                          be used, if possible. this an earlydata can
                                                                                         ment when deciding whether or not to
                                                                                         probe apparently healthy tissue. In
Brushing should be                                              tor of problems in       observing signs of infection, the clini-
the primary aspect of the oral hygiene    the dental implant. The dental hygien-         cian should probe the periimplant tis-
program. To maximize compliance,          ist should begin by noting the prosthe-        sue.32,38 Probing should be accomplished
only one auxiliary aid should be used,    sis design. It also can be helpful to note     with a plastic periodontal probe (Figure
if possible.30                            any inherent problems in the design            11). Ideal pocket depths are under 4 mm
                                          that can affect plaque removal. An             and there should be no bleeding. Color,
                                          account of the types of implants and           consistency, and presence or absence of
Mucogingival Tissues                      their locations also should be recorded.13     edema should be assessed by visual
                                                Poor surgical technique, traumatic       examination. Slight pressure on the soft
     Because of osseointegration, the     occlusion, or inadequacies in the pros-        tissue can produce bleeding, exudate, or
implant can function as a natural tooth.  thesis can all cause bone loss.This bone       tenderness in inflamed periimplant tis-
However, it is unlike a natural tooth in  loss results in a reservoir for bacterial      sue. The clinician also should measure
its susceptibility to disease and the     colonization and further breakdown of          recession.13 The absence of keratinized
rapid destruction of the surrounding      the periimplant tissues.70 The hard-tis-       tissue has not conclusively been shown
tissues. Although the soft tissue of the  sue evaluation should include radi-            to predispose implant tissue to disease;
tooth and implant resemble each other,    ographs, evaluation of occlusion, and          however, the presence of keratinized tis-
there are inherent differences in the     examination of the prosthesis. Radio-          sue surrounding the implant can make
connective tissues. The periodontium      graphs should be taken to monitor              oral hygiene procedures easier to
of a natural tooth consists of alveolar   bone levels around the implant and             accomplish.71
bone, periodontal ligament, cemen-        evaluate the health of the bone.A peri-             The dental hygienist should keep a
tum, and the gingiva. The implant is      apical X ray with correct density and          record of the client’s home-care proce-
surrounded by periimplant tissues and     angulation, taken with a paralleling           dures including recommended aids and
lacks a periodontal ligament. The sur-    technique, can display marginal bone           chemotherapeutics.The client’s respons-
face of the a tooth has a connective tis- loss and components of the prosthesis.15       es and attitudes toward the home-care
sue attachment with collagen fibers       The dental hygienist should document           procedures should be noted as well.
inserted into the cementum. The con-      the radiographic technique and repeat          This will allow assessment of the suc-
nective tissue in the implant is com-     it at future examinations to promote an        cess or limitations of this regimen in
promised because collagen fibers run      accurate comparison.13                         the future (Figure 12).13

8 special supplemental issue—Access
Maintenance                                or occlusal stress on the implant. All
                                           surfaces of the prosthesis should be free
     In the first year following restora-  of scratches, fissures, and gouges that
tion of the implant, frequent recalls are  can harbor bacterial plaque.13
needed. The client should be assessed           The evaluation of the health of the
every three months. Recall for the         periimplant tissue should include clini-
implant client after those initial 12      cal inspection for signs of inflammation.
months should be dictated by the           The dental hygienist should also note
client’s individual needs. These factors   the nature of deposits on the implant
                                                                                        Figure 11. Use of the plastic probe.
include stability of the implant tissues,  abutment. The presence or absence of
periodontal health of the surrounding      debris, plaque, and supragingival or sub-
teeth, systemic health, and the effec-     gingival calculus should be noted and
tiveness of home-care procedures.32        further quantified as light, moderate, or
     Maintenance visits include periim-    heavy.13
plant evaluations, prosthetic evalua-           Removal of deposits should be
tions, deposit removal, home-care rein-    accomplished only with instruments
forcement and modifications, and radi-     that are incapable of damaging the
ographs when indicated. A comparison       implant surface. A variety of instru-
of findings to baseline data can indicate  ments similar to curets and scalers are
impending problems with the                available in plastic, nylon, or graphite.
implant.13                                 Gold-tipped instruments can be used
     In the first year of treatment, radi- but must be examined before use for          Figure 12. Measuring the keratinized gingiva.
ographs of the implant should be taken     exposure of the underlying metal and         The metal probe should never be used to probe
at each three-month recare visit. After    should never be sharpened.32 If a client     around the implant.
that, an annual radiograph should be       is performing an effective home-care
taken and compared to the baseline         regimen, subgingival calculus should         ment, the metal instruments must be
radiograph. Because of surgical trauma,    be light. Calculus is not firmly attached    covered with plastic tips.13,32,67 The air-
it is reasonable to ex-                                     to the implant because      powered abrasive unit is contraindicated
pect 1.5 mm of bone                                         of the nonporous tita-      by some investigators.A review of sever-
loss in the first year and In the first year of nium surface and                        al studies examining several types of
0.2 mm each year                   treatment,               should be easily remo-      instruments and their effects on the
thereafter.32,40 Exces-                                     vable. The dental hy-       implant surfaces reveals the air-abrasive
sive bone loss must be radiographs of the gienist should scale                          unit to be safe and effective in removing
addressed immediately. implant should be with short working                             deposits.72-75 A rubber cup can be used to
     Implant mobility                                       strokes and light pres-     polish the implant surface with a
can be a sign of signif-        taken at each               sure to prevent trauma      nonabrasive paste or tin oxide.15,32,67
icant problems. Stabi-           three-month                to the delicate periim-           As home-care factors greatly into
lity of the implant                                         plant sulcus. Upon          health of the implant, the dental hygien-
should be assessed at             recare visit.             insertion of the instru-    ist should motivate the client to continue
each recare appoint-                                        ment, the blade should      the regimen. If home care has not been
ment.Mobility can occur at the abutment-   be closed against the abutment and           effective, the dental hygienist should
prostheses connection and requires         then opened past the deposit. The            question the client and attempt to
repair.13 Mobility of the implant body     deposit should be engaged apically           resolve those issues. If the employed aux-
is more serious, as it implies a loss of   with the stroke extending coronally. A       iliary aids are not effective, it may be
integration.15                             horizontal, oblique, or vertical stroke      necessary to modify or change the client’s
     The prosthesis and attachments        should be used, depending on the loca-       techniques or change the type of aid.
should be examined for adequacy and        tion of the deposit.13                             The dentist should be immediate-
continued function. Mechanical diffi-           Prostheses can sometimes limit          ly be informed of any problems or
culties in the prosthesis, such as a frac- access of the scaler, and an ultrasonic or   concerns. Changes in implant health
ture, can cause excessive occlusal stress  sonic scaler can facilitate removal of       must be addressed immediately, as
and contribute to periimplant bone         deposits.When using the sonic or ultra-      should problems related to occlusion,
loss.40 There should be no undue force     sonic device to scale the implant abut-      prosthetics, and mobility.13

                                                                                    Access—special supplemental issue 9
                                                     Periimplant mucositis is similar to  Summary
                                                gingivitis around a tooth in its bacteri-
                                                al etiology and its reversibility. This        Although the dental implant
                                                bacterial infection is marked by inflam-  requires constant maintenance and
                                                matory changes with bleeding on           monitoring, it can be a predictable
                                                probing, edema, and tenderness. Its       replacement for natural teeth. Studies
                                                unchecked progression can lead to         have shown that implants can be supe-
                                                periimplantitis, which affects the sur-   rior to removable prosthodontics in
                                                rounding bone. Increased pocket           aesthetics, stability, and chewing forces.
Figure 13. Radiograoph of a treated “ailing”    depth, presence of exudate, and bone      From education to assessment, the den-
implant.                                        loss accompany the inflammation in        tal hygienist is a constant in a dynamic
                                                the periimplant soft tissue (Figures 13   process. The capacity of the dental
                                                and 14).15,32,33                          hygienist to function within the
                                                     The ailing implant demonstrates      implant team is a great benefit to the
                                                radiographic bone loss without clinical   potential and current implant candi-
                                                inflammation.The pocket depth can be      date.
                                                advanced but is marked by the absence
                                                of bleeding. The inflammatory process
                                                may have been arrested
                                                or bone loss could have
                                                resulted from trauma.
                                                                                  There is no
                                                The ailing implant must         treatment for
Figure 14. Radiograph of an “ailing” implant.   be monitored closely at
                                                each maintenance visit.38
                                                                                   the failed
                                                     The failing implant       implant and it
                                                presents with consistent
                                                deterioration at mainte-
                                                                                    must be
                                                nance intervals (Figure            removed.
                                                15). Inflammation is pres-
                                                ent and observable with signs of bleed-
                                                ing, edema, redness, and exudate.There
                                                is no mobility, but radiographic bone
Figure 15. A failing implant with purulent
                                                loss is detectable. Intervention for the
                                                failing implant can be successful.
                                                Treatments include detoxification of
                                                the implant surface and surgical inter-
                                                ventions. The source of the problem
Ailing/Failing Implants                         must be identified and eliminated.38
                                                     Implant failure is multifactorial
     The biological reaction of the             and the cause may be unidentifiable.
implant to pathogenic bacteria can              The progression of inflammation and
have an impact in the long-term suc-            traumatic forces can result in destruc-
cess of the implant. It is for this reason      tion of the bone. The failed implant
that thorough examination of the                presents with clinical inflammation,
implant structures at maintenance visits        radiographic bone loss, and clinical
is indicated. Changes in implant health         mobility. There is no treatment for the
can indicate if the implant is ailing or        failed implant and it must be
failing, or has failed.38                       removed.38

10 special supplemental issue—Access
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