July 1, 2012
by Joseph Massad, DDS
The demographic data indicates that, in general, individuals are living far longer than they did previously. As longevity increases, so does edentulousness. While improved oral health is enabling many people to maintain their teeth longer into life, some tooth loss does eventually occur. The number of edentulous arches in the population has decreased as a percentage, but increased as an actual number.
Today, implant therapy is a very effective vehicle in the fabrication of prosthetic restorations for the management of the edentulous patient.
With all the prosthodontic options available, practitioners are confronted with numerous, very confusing challenges. It is very essential that dentists develop an accurate diagnosis utilizing various tools including pre-prosthetic records, and enhanced CT radiography with its associated predictive software. Current state of the art techniques, and decades of experience and study, enable the practitioner to provide a range of treatment planning options, combining options in complexity and cost, to patients.
In this world of high technology, however, the profession sometimes loses sight of the ongoing home-care that is required of the patient after the completion of the surgical and restorative phases. The importance of proper home hygiene for prosthetic implants cannot be overstated. In fact, there is a fundamental need to include maintenance instruction, and re-instruction, as a part of the pre-treatment plan.
It is well-accepted that the accumulation of bacterial plaque and the formation of organized biofilm1 cause reversible inflammatory changes in the peri-implant soft tissues.2 This condition is commonly designated as “peri-implant mucositis.”3 The long-term prevalence of peri-implant mucositis has been reported to be as high as 76.6%. If untreated, and in the absence of effective oral hygiene practices, peri-implant mucositis may cause a significant deterioration of the osseous tissues supporting the implant, known as “peri-implantitis.”4,5 Although numerous therapeutic intervention methods for peri-implant mucositis and peri-implantitis have been described, preventing the damaging effects of these pathologic conditions before they have a chance to pose a threat to the retention of the implant should be the profession’s goal for all implant patients.6-8
The awareness of these possibly damaging post-surgical and post-restorative developments secondary to the lack or absence of implant hygiene mandates the practitioner professionally, ethically and legally to educate, train, and motivate patients. First, the patient must be taught what the expected clinical outcome is likely to be if either in-office or at-home preventive maintenance schedules are not followed. Even prior to implant therapy, patients should be advance scheduled for post-treatment professional hygiene appointments. They must also be thoroughly educated in home maintenance. They should signify the acceptance of these parameters by signing a responsibility acceptance form as a condition of implant treatment.
When reviewing at-home care for implant patients, it is important to remember that keeping tissue-implant-prosthetic connections clean may be very challenging, particularly when the patient is limited to direct manual access. Two innovative approaches that facilitate this process follow.
There are many, many advantages to cleansing implant connections daily with powered toothbrushes that mechanically remove debris from contaminated surfaces. Powered brushes allow patients to focus on specific tissue-implant-prosthetic interfaces when utilizing specifically designed brush heads in combination with measured bristle pressure and engineered rotational and oscillating movements. Recent investigations indicate that an oscillating-rotating movement removes more plaque than a manual toothbrush.9-12 The Oral-B Professional Care SmartSeries 5000 powered toothbrush with Wireless SmartGuide (Procter & Gamble, www.pg.com) is an oscillating-rotating powered toothbrush that offers various heads to negotiate the tissue-implant-prosthetic interfaces accompanied by an online patient step-by-step instructional animated video for the various prosthetic restorations. (English version link http://youtu.be/NAXD2yLq9WQ, Spanish http://youtu.be/3igV5rOkpxA)
Many patients forget to, or cannot be bothered carrying a power brush while travelling. In these cases, it is good practice to give each implant patient a manual overnight trip brush to insure compliance while away. The smaller bristle configurations found on pedodontic brushes can replace the power toothbrushes effectively for short periods of time while the patient is away from home. The figures below demonstrate how two pedodontic brushes function as a traveling substitute, and can easily engage the various implant angles due to their small size, reducing the buildup of unwanted biofilm. An ongoing dialogue is necessary with implant patients to provide an awareness that the lack of continual implant maintenance may in many cases create an environment that is detrimental to the life span of the dental implant.
Another method for the successful and efficient elimination of peri-implant biofilm (Fig. 12) and mucosal irritation is water flossing.17 The Waterpik Ultra Water Flosser (Fig. 13) uses a pulsating stream of water to gently but firmly remove debris and bacterial matter from the tissue-implant-prosthetic interfaces. A gentle stream of pressurized water, allows the patient totally convenient access and rapid cleansing during their at-home implant maintenance. The water can access areas that are inaccessible through other means. There are numerous studies that demonstrate the efficacy of a water flosser in reducing plaque,13 subgingival bacteria,16 gingivitis15 and bleeding.14
With the tremendous growth of implants and the possibility of neglect-associated destructive peri-implantitis, the professions’ opportunity (and responsibility) to educate all implant recipients in proper oral hygiene methods is clear. This instruction serves to improve patients’ implant health and oral health, and decrease the possibility of premature implant loss.
The figures here display stills of the rotary handle and various brush heads very useful in negotiating different prosthetic configurations. OH
Dr. Massad practices privately in Tulsa, OK. He holds faculty positions at Tufts University School of Dental Medicine in Boston, and the Department of Comprehensive Dentistry, University of Texas Health Science Center Dental School San Antonio Texas, and The Department of Prosthodontics at the University of Tennessee Health Science Center, Memphis Tennessee. He has previously held a faculty position at the Oklahoma State University College of Osteopathic Medicine Oklahoma, and has been a past Director of Removable Prosthodontics at the Scottsdale Center for Dentistry in Arizona from 2006 – 2010. Dr. Massad served from 1992-2003 as an associate faculty at the Pankey Institute in Florida. Dr. Massad is a fellow of the American College of Dentists, the International College of Dentists and Fellow/Regent of the International Academy for Dental Facial Esthetics.
Oral Health welcomes this original article.
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14. Rosema NAM, Hennequin-Hoenderdos NL, Berchier CD, Slot DC, Lyle DM, van der Weijden GA (2011) The effect of different interdental cleaning devices on gingival bleeding. J Int Acad Periodontol 13:2-10.
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17. Felo A, Shibly O, Ciancio SG, Lauciello FR, Ho A. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent 1997; 10(2):107-110.
Barnes CM, Russell CM, Reinhardt RA, Payne JB, Lyle DM (2005) Comparison of irrigation to floss as an adjunct to toothbrushing: effect on bleeding, gingivitis, and supragingival plaque. J Clin Dent 16:71-77.
Rosema NAM, Hennequin-Hoenderdos NL, Berchier CD, Slot DC, Lyle DM, van der Weijden GA (2011) The effect of different interdental cleaning devices on gingival bleeding. J Int Acad Periodontol 13:2-10.
Chaves ES, Kornman KS, Manwell MA, Jones AA, Newbold DA, Wood RC. Mechanism of irrigation effects on gingivitis. J Periodontol 1994; 65(11):1016-1021.
Flemmig TF et al. Adjunctive supragingival irrigation with acetylsalicylic acid in periodontal supportive therapy. J Clin Periodontol 1995;22:427-433.
Felo A, Shibly O, Ciancio SG, Lauciello FR, Ho A. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent 1997; 10(2):107-110.