Communicate, coordinate, and create: Successful implant cases

In the future, dental professionals can expect to see a growth in the number of implant patients we treat. The following demographic trends support and reflect this:

→Older Americans make up a growing percentage of the U.S. population (according to the 2000 U.S. Census, nearly 35 million are 65 years or older. By 2050, that number is expected to increase to 48 million).

→About 30 percent of adults 65 years old and older no longer have any natural teeth.

→By age 50, Americans have lost an average of 12 teeth and, among adults 65 to 74 years old, 26 percent are totally edentulous.

→Implant manufacturers are presenting product innovations that are simplifying the restorative aspect, as well as patient comfort and the convenience of implant therapy.

→The average number of surgically placed dental implants by dentists increased by 49 percent from 1995 to 1999.

→As technology has developed and improved, the success rate of dental implants is approximately 90 percent.

Clearly, dental professionals have a huge opportunity to see continued growth in implant patients.

With the increasing volume of cases, it could be easy for details to be overlooked. Therefore, continuous communication with all clinicians involved is essential.

Success depends on the team approach

When you consider all the dental professionals potentially involved in the implant process, the complete team may include surgeon (general dentist or specialist), restorative dentist (general or specialist), dental hygienist, dental assistant, lab technician, dental business staff, and, if needed, an endodontist and an orthodontist. All team members should be included in the circle of communication throughout the entire implant treatment.

Surgeon

When a general dentist performs the surgery, he or she is usually also the restorative dentist.

Restorative dentist

The role of the restorative dentist (specialist or generalist) is critical as the initial “implant team coordinator.” Careful consideration must be given to the selection of the candidate to ensure the ultimate success of the case.

Other responsibilities of the restorative dentist include:

→Understanding the surgical considerations for implant placement

→Directing the referral to the appropriate implant team members

→Coordinating surgical placement and restorative treatment planning and

→Orchestrating a comprehensive prosthetic treatment plan

Dental hygienist

The dental hygienist can benefit greatly from increasing general implant knowledge. If an implant surgery has not been observed, it would be advisable to arrange this with one of the referring surgeons. This experience is invaluable for a complete understanding and discussion of the procedure.

Continuing education (CE) courses on implant maintenance, as well as following articles in dental and dental hygiene journals, assist the dental hygienist in keeping abreast of the latest technology, products, and trends. The Internet is also another great resource. Philips Oral Healthcare offers a CE course called, “Dental Implants: The Basics and Beyond” (check www.sonicare.com for details about this program). Another resource for CE is the International Congress of Oral Implantology’s Association of Dental Implant Auxiliaries (ICOI ADIA) Web site - www. dentalimplants.com.

The dental hygienist participates in patient selection, maintenance assessment, and oral hygiene instruction. Once the case is completed, the dental hygienist can take over as team coordinator. Continued communication with the surgeon helps complete the circle of care.

Patient selection

With the persistence of partial and total edentulism, many patients are potential implant candidates. Dental hygienists establish relationships with patients through the years and, along with the dentist, are in an ideal position to discuss implant therapy as a treatment option. A thorough knowledge of the patient’s medical history - as well as a good understanding of the psychological profile - assist them in making suggestions and informing them of various treatment options. The team should also be aware of patients who may be poor candidates, e.g. medically compromised, active periodontal disease, smokers, unwilling or unable to perform adequate oral dental hygiene, and unwilling or unable to assume the necessary time and financial commitments. In addition to these constraints, the dentist and/or surgeon may screen out some potential candidates due to anatomical obstacles or medical conditions.

Once a patient has been identified as a potential candidate, the dental hygienist can incorporate implant information into the dental hygiene appointment. Tools available to assist in this education process may include videos/DVDs, brochures, models, before-and-after photos, and books.

Maintenance assessment

After implant case completion, the dental hygienist assumes the role of the team coordinator. A thorough assessment should occur at each dental hygiene visit and certain protocols should be followed consistently:

*Frequency of hygiene maintenance visits - This should be decided upon by the maintenance team (dentist, surgeon, and dental hygienist).

*Patient self-reporting of history - The patient should be questioned about comfort of implant(s). Any pain and/or sensitivity should be brought to the attention of the dentist as soon as possible.

*Clinical evaluations - Evaluations should regularly include:

1. mobility check (mobility could result from a loose prosthetic or from breakdown of the implant structure itself and would require further investigation);

2. digital palpation of the tissue in the vicinity of the margin to determine the presence of suppuration or bleeding;

3. adjacent tissue evaluation; and

4. plaque control

In addition, probing (optional per clinician) and radiographs would be performed (as agreed upon by the maintenance team). All clinical findings should be shared with the dentist at the dental hygiene appointment.

Radiographs and probing

The frequency of radiographs and probing is subject to conflicting opinions and controversy. Therefore, the dental hygienist should contact the referring surgeon, as well as the restorative dentist, to determine an agreed-upon plan.

*Radiographs - According to Lynn Mortilla, RDH, executive director of the Association of Dental Implant Auxiliaries and Practice Management, “Baseline radiographs should be taken the day of prosthesis delivery, six months post-prosthesis delivery, and one year post-delivery. If there are no radiographic changes, radiographs should be taken every three years. If there are signs of pathology, clinical symptoms, mobility, or advanced bone loss, diagnosis and treatment should be initiated and a radiograph should be taken every six months for one year after the problem has ceased or been corrected.”

*Probing - Probing is quite controversial. Many clinicians feel that it is difficult to obtain an accurate reading due to the emergence profile. Beyond that, probing may disturb the fragile attachment mechanism. Again, the team determines whether this diagnostic procedure is to be performed and, if so, how frequently. Plastic probes should be the only choice and some have a pressure sensor to ensure that no more than 20 grams of pressure are utilized. As an additional safety measure, the probe should be dipped in chlorhexidine to avoid introducing bacteremia into the site. A baseline reading is critical to compare to subsequent evaluations. Naturally, bleeding as well as the probe measurement should be recorded. However, bleeding alone is not a sign of disease.

Communication and follow-up

In order to fulfill the goal of continuous communication, the dental hygienist should send an annual follow-up note to the surgeon. The best time to do this would be after the annual radiograph and probing appointment.

Dental hygiene maintenance

Upon completion of the treatment (i.e., prosthesis is seated), the patient begins the maintenance stage. Hygiene maintenance therapy intervals (recare) and oral hygiene are discussed. Patients may be enthusiastic about their new “teeth” at first, but quickly forget the special care and commitment required for a lifetime.

If practical, a brochure or customized patient handout can be created for the office, detailing the particulars about each patient’s case along with recommendations for oral hygiene.

A variety of devices are available for oral hygiene maintenance. Some are specifically designed for implants, but many are recognized for everyday oral hygiene use.

Toothbrushes

There are a variety of toothbrushes available, and this can make the selection overwhelming. Power toothbrushes have become a popular choice due to their ease of use as well as the thorough plaque removal they provide. Research has shown their superiority in several clinical parameters. In a four-year prospective study which included 18 participants with a total of 29 implants, the Sonicare® Advance power toothbrush was statistically more effective in maintaining healthy periimplant soft tissues, as well as preventing increase of pathogenic morphotypes in periimplant plaque, than a manual toothbrush.

Interdental aids

There are many interdental choices. The selection depends on several factors, such as removable or fixed prosthesis, single or multiple implants, abutments exposed or not visible, etc. Some products that work especially well include Thornton Bridge and Implant Cleaner (Thornton International, Inc.) soaked with chlorhexidine (Peridex®, Omnii Oral Pharmaceuticals™), AIT Proxi-Tip™ Interproximal Brush and Stimulator and AIT Proxi-Floss™ (AIT Dental), and End Tufted Brushes (Sunstar Butler GUM® Specialty Brushes).

The team should be dedicated to enhancing patient compliance and cooperation. The dental office can attend local conferences to review the latest technology and products, obtain samples, and select the most appropriate self-care items. The office can also have staff meetings, which include a product review of recommended tools specific for your implant patients. All members of the implant team should be educated to answer patient questions. Product selections should be discussed with the surgeon and included in any custom patient brochures being offered.

Conclusion

The increase in implant cases will offer many opportunities as well as challenges for the dental professional. Continual communication and a team approach is an excellent strategy to promote success for all participants.

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After 15 years in the corporate environment working in various sales, marketing, and advertising positions and receiving her MBA degree, Leslie Andrews pursued her dental hygiene education at the University of Bridgeport. She graduated with honors from the Fones School of Dental Hygiene. She has a passionate interest in holistic medicine and natural healing. Andrews is a member of the American Academy of Dental Hygiene and serves as Eastern Trustee to the national chapter of Sigma Phi Alpha. Andrews currently practices dental hygiene part-time in Connecticut. She can be reached by e- mail at [email protected].