1 Implant Maintenance Curriculum Among U.S. Dental Hygiene

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Implant Maintenance Curriculum Among U.S. Dental Hygiene Programs

Thesis

Presented in Partial Fulfillment of the Requirements for the Degree Master of Dental

Hygiene in the Graduate School of The Ohio State University

Sarah Jane Youssef

Graduate Program in Master of Dental Hygiene

The Ohio State University

2020

Thesis Committee

Brian B. Partido, BSDH, MSDH, Advisor

Rachel Kearney, BSDH, MS

Damian Lee, DDS, MS, FACP

Copyrighted by

Sarah Jane Youssef

2020

Abstract

Purpose: There is a range of clinical practices that dental professionals use to maintain implants, revealing a need for a more standardized approach. The purpose of this study was to determine the curricular content for dental hygiene programs in the U.S. regarding implant maintenance. This research aimed to find out if that curricular content aligned with the CPG published by the ACP. Methods: This descriptive research study utilized a survey to explore the implant maintenance curriculum in U.S. dental hygiene programs.

Descriptive statistics were used to examine the data. Results: A total of 53 participants responded to the survey (n=53). 100% of programs felt that implant maintenance was important to include in the curriculum and 98.1% teach implant maintenance. This study helped identify the curricular content for implant maintenance: 94.3% teach preventative care techniques, 90.6% teach appropriate tools/materials, 92.5% teach patient education,

88.7% teach radiographic interpretation, and 83.0% teach recall frequency. This research has helped recognize where the curricular content aligns with the current CPG published by the ACP and that most programs are not utilizing the CPG as a resource for curricular development. Conclusion: Dental hygiene programs are teaching dental implant maintenance but there is variety among the content and the resources used to develop that content. If more programs were to standardize their content, there could be less variety in treatment modalities in clinical settings for implant maintenance.

Acknowledgments

I would like to express my sincerest gratitude to my advisor and mentor, Brian Partido, for the guidance, encouragement, and unwavering patience that he has provided to me throughout this lengthy process. I would also like to thank my committee members,

Rachel Kearney and Damian Lee, for the support and inspiration that they offered me.

iii

Vita

2013…………………………...….AAS in Dental Hygiene, Youngstown State University

2013-Present………..Registered Dental Hygienist in a Public Health Clinic, Akron, Ohio

2018……………………………....……BS in Dental Hygiene, The Ohio State University

Fields of Study

Major Field: Dental Hygiene

Table of Contents

Abstract ...... ii Acknowledgments...... iii Vita ...... iv List of Tables ...... vi Chapter 1. Review of the Literature ...... 1 Chapter 2. Materials and Methods ...... 19 Chapter 3. Results ...... 22 Chapter 4. Discussion ...... 30 References ...... 35 Appendix A. Tables ...... 39 Appendix B. Survey ...... 46

List of Tables

Table 1. Demographic Characteristics of surveyed U.S. dental hygiene programs……43

Table 2. Frequencies pertaining to Clinical Practice Guidelines……………….……...44

Table 3. Frequencies of what the curricular content for dental implant maintenance is in dental hygiene programs………………………………………………………………..45

Table 4. Frequencies for the recall intervals that dental hygiene programs recommended to their students……………………………………………………….……..………….46

Table 5. Frequencies of dental hygiene programs timing and course type for dental implant maintenance training…………………………………………………………...47

Table 6. Frequencies for resources used to develop curricular content……….……….48

Chapter 1. Review of the Literature

Background of the Problem

Dental implants are quickly becoming the treatment of choice for replacing missing dentition and restoring dental function. According to the American Academy of

Implant Dentistry, over 3 million people in the U.S. have dental implants and that statistic is growing by 500,000 each year.1 The regular maintenance of dental implants, including homecare, professional preventative dental care, and dental exams with images, is essential for their long-term success.2–4

There is a wide range of clinical practices that dental professionals use to maintain implants often determined by the individual clinic that treatment is being performed in, which reveals a need for a more standardized approach for dental implant maintenance.4–6 Dental hygienists are frequently the clinicians that are facilitating dental implant maintenance and a knowledge gap has been identified as to what the curricular content is for student dental hygienists regarding dental implant maintenance.7 Due to the significant range of clinical practices that are used and to fill the identified knowledge gap, this study will explore what curriculum is being taught to student dental hygienists about dental implant maintenance. This knowledge gap will be discussed further along with the relative factors involving dental implant maintenance, including an overview of implants, the need for dental implant maintenance, what dental hygiene programs offer

1 for dental implant maintenance through their curriculum, and how that curricular content is aligned with the current clinical practice guidelines for dental implant maintenance.

Review of the Literature

History of Implants

For two millenniums, humans have been finding ways to replace missing teeth and restore masticatory function. While radiographing ancient skulls in the 1970’s, it was discovered that indigenous Mayans were inserting pieces of shells into the mandible effectively replacing missing teeth dating as far back as 600 AD.8 The radiographs showed compact bone formation around the implanted shells in a manner that is similar to how blade implants osseointegrate.8 A similar situation was found in to have occurred around 800 AD when an early Honduran culture first carved a stone and then inserted it into the mandible.8 These early attempts and successes were the starting ground for dental implants.

From the 1500’s-1800’s many discoveries in jaw and dental anatomy were made by way of cadaver study.8 Dr. John Hunter spent years systematically dissecting cadavers that were procured by grave robbers, documenting in detail the anatomy of the jaw and mouth.8 During that time span, there was much experimentation with allotransplantation, or the transplantation of real teeth, that came from either impoverished people or cadavers throughout Europe.8,9 Unfortunately, most of the roots on the transplanted teeth would be resorbed by the host body after a period of time.9 Dr.

Hunter’s discoveries in anatomy of both the mouth and jaw and his subsequent comprehensive documentation of it, along with his studies of tooth allotransplantation,

2 helped pave the way for future generations of dentists to further hone their approach to dental implants.

The exploratory research that had been conducted in the 1800’s led to a significant increased pace in progress towards successfully placed dental implants for the early 1900’s. Many types of materials were tested for biocompatibility for their use in dental implants, such as, silver capsules, corrugated porcelain, gold tubes, and iridium tubes.8 In 1913, Dr. E. J. Greenfield was repeatably placing and restoring dental implants made from an iridio-platinum lattice-like cylinder that was soldered with 24-karet gold.9

His implant was hollow and allowed the bone to completely fill inside the mesh-like cylinder, then he would attach the crown portion after a period of healing—this was a concept that he felt gave the implant greater retention in the bone.9,10 Dr. Greenfield wrote down the materials that he used, the detailed surgical procedures for the dental operation, and his advice for restoring the artificial roots—his name for dental implants.9

He also traveled throughout the United States teaching clinicians the same procedures.9

The fact that this process was able to be replicated by both Dr. Greenfield and the clinicians that he trained further progressed the development of implants.

In the 1930’s, advancements were made in material selection for dental implants that were both biocompatible and strong enough for the task at hand. In 1939, Dr. Alvin

Strock inserted a screw made from vitallium into a fresh extraction site.10 Vitallium, a chromium-cobalt metal alloy, was discovered by Dr. Strock to be biocompatible, leaving the surgery site with no adverse reaction.8,10 The material was also strong enough that after a period of healing he attached a prosthetic crown on the screw.10 He felt that the

3 stability of the prosthesis came from the inherent design of the screw as opposed to the bone filling in around it.10 Due to the immense success of the vitallium screw, Dr. Strock has been acknowledged as the first person to successfully place an endosteal implant, the type of implant that is used most widely today.8 Dr. Strock’s research on biocompatible and functional materials has opened the door for today’s implant materials.

A key set of discoveries starting in the mid-1950’s by an orthopedic surgeon in

Sweden, Dr. Per-Ingvar Brånemark, proved the long-term success of titanium implants.10

Dr. Brånemark was using titanium chambers implanted within bone to research blood flow and found that titanium is not just biocompatible, but that it becomes embedded into the bone—a process that he described as osseointegration.11 The areas where the bone and the metal have become osseointegrated are actually stronger in constitution than the surrounding bone, and he found that the bone has the ability to fill in around the dental implant in the smallest of spaces.11 Dr. Brånemark first placed dental implants in dogs and found that after ten years healthy bone and soft tissue could be maintained.11 After the accomplishments in research of the ten year study in dogs, dental implants were placed in edentulous human patients with great success, maintaining both bone and gingival health.11 A 15-year follow-up study on his dental implant cases was also published, prompting the universal acceptance that root-form endosseous titanium implants are the treatment of choice for replacing missing teeth.10 Dr. Per-Ingvar

Brånemark’s meticulous documentation and follow-up have allowed the modern dental implant—the root-form endosseous titanium dental implant—to be born and to thrive.

After Dr. Brånemark’s research on osseointegration was well distributed, innovations on implant loading procedures and surface roughness of dental implants was sought after to enhance and maintain the osseointegration process. In 1974, Dr. André

Schroeder and his research team commenced researching a previously accepted concept that a fibrous tissue connection between the bone and the implant could provide shock absorbing capabilities, similar to how the periodontal ligament functions on a natural tooth.10 Dr. Schroeder investigated the bone-to-implant interface (i.e. an osseointegrated implant) at a microscopic level in comparison to the bone-fibrous tissue-implant interface

(i.e. an implant with infused connective tissue cells between the implant and the bone) using a histological approach, discovering that the osseointegrated implant was more favorable to withstanding the masticatory forces present after restoring.10,12

Dr. Schroeder also investigated the concept of roughening an implant’s surface to increase contact area for the implant-to-bone connection.10 His research team—known as the International Team of Oral Implantology (ITI)—developed a titanium-plasma sprayed surface roughened implant in 1979.10 ITI’s research documented that the increased surface area of the surface roughened implant allowed for faster restoration and loading, as well as being even more biocompatible than a smooth-surface implant due to the increased contact between the bone and the implant.10 These studies have been repeated in a variety of ways, including Yang, et al.’s research has shown that an implant that has had its surface roughened is consistently superior to smooth surface implants for bone- implant contact, thereby promoting an increased level of osseointegration.13 Dr.

Schroeder and his ITI group’s research enabled implantology to move forward, enhancing an already functioning design.

Modern dental implants have developed through the trials and tribulations of the researchers that sought to replace missing teeth, restoring masticatory function and esthetics on the way. Dr. John Hunter pioneered the field of mouth and jaw anatomy through his examination of cadavers and his subsequent detailed documentation of his findings in the 1700’s.8 Dr. E. J. Greenfield identified, recorded, and shared his surgical skills in 1913 that are still being used today.9 The introduction of a biocompatible material by Dr. Alvin Strock in 1939 and the first successful placement of an endosteal dental implant paved the way for the use of material sciences in dental implant research.10

Dr. Per-Ingvar Brånemark’s paramount research that started in the mid-1950’s and continued on with exemplary documentation and follow-up into the 1980’s proved the long-term success of titanium dental implants.11 The use of coated dental implants to increase surface area and improve osseointegration was introduced by Dr. André

Schroeder in 1974 and forever changed the way that implants are made.10 Extensive amounts of research and centuries of perseverance has led to the regular use of dental implants to restore missing teeth and, after all that, protocol for the proper maintenance of implants needs to be ensured to maintain the health of the peri-implant tissues.8–11,13

Overview of Dental Implants

A dental implant is a device that is surgically placed underneath the soft tissue and directly into or on the mandible or maxilla so that a prosthesis—a crown, bridge, or denture—may be attached.14 Once restored, dental implants help to reestablish

6 masticatory function, speech, esthetics, and, in many cases, self-esteem.15 Before final restoration, osseointegration—a functional unification between the implant and the bone—of the dental implant must occur.12 Once osseointegration does occurs, the focus for maintaining the health of the implant revolves around preserving the biological seal that exists where the dental implant is exposed to the gingiva.16

A finished dental implant consists of three parts: the fixture, the abutment, and the prosthesis.17 Today’s fixtures are typically a root-form titanium screw that is surgically placed within the bone (endosseous) and allowed to osseointegrate in place.17

Other versions of fixtures that are not used as frequently as endosseous implants include both the subperiosteal (a metal framework that sits on the bone of the mandible or the maxilla under the periosteum) and the transosseous (implanted through the full thickness of the alveolar bone).12 There are three main types of endosseous implants, including blade, cylinder, and screw type, with the screw type being the most widely used today.12

Alterations to the exterior surface of the fixture—such as surface roughening, chemical modification, thermal treatments, and laser treatments—can be used to enhance the osseointegration process by increasing overall surface area so that forces are more widely distributed.8 The fixture is often referred to as the dental implant and the main concern is that osseointegration is achieved.

The abutment is an attachment that connects the implanted fixture with the prosthesis, acting as an interface between the two.17 After the implant is initially placed, the clinician will either immediately insert a cover screw or a healing abutment into the exposed hollow access hole at the gingival end of the implant so that neither soft tissue

7 nor bone forms into that space during healing time.17 The use of a cover screw allows for primary closure of the wound during healing.17 A healing abutment allows for secondary intention healing, or healing with a specific outcome in mind, letting the gingiva form in a shape that is conducive to both esthetics and function of the final prosthesis.17 After 3-

6 months of the dental implant healing within the bone, the process of restoration can start by removing the healing abutment and placing the final abutment for restoration.17

A dental prosthesis is the functional end of the implant system, allowing for the restoration of masticatory function or esthetics due to an incomplete dentition. A final prosthesis can be a single crown, a bridge, or a denture-type prosthesis, allowing for multiple ways to restore dental implants to suit the individual patients’ needs.17 If planned properly allowing for the proper distribution of forces, a one-to-one implant to prosthesis ratio is not needed for restoration, and a complete arch 14-tooth prosthesis can be attached to just six implants.17 The dental prosthesis that is attached to an implant needs all of the care and planning that the implant fixture received during its surgical placement.

A properly planned and executed implant, along with the resulting restoration, is necessary to allow for ideal function, as well as promoting long-term success. The precise placement and angulation of the dental implant within the bone is essential to allow for the appropriate distribution of forces, minimizing the stress and resulting negative impact on the bone.17 Consideration to margins, embrasure shapes, crown contours, contact areas, and harmonious occlusion is necessary to have a final prosthesis that thwarts biofilm retention and allows the patient to perform thorough home-care, all

8 of which is necessary for a successful implant.12 The placement of the dental implant, the soft-tissue shaping with the healing abutment, and the function of the dental prosthesis all need to be executed in a manner that allows for both professional implant maintenance to be performed and for effective home-care to be administered.

Peri-Implant Tissues

A thorough knowledge and successful management of peri-implant soft and hard tissues is crucial to the longevity and esthetics of a dental implant. Peri-implant tissues are similar, but not an exact match for the tissues that surround a natural tooth, and are comprised of both an intra-osseous component and a transmucosal component—very similar to how teeth are.16

The intra-osseous portion resides within the alveolar bone and provides the physical support, holding the implant in place.16 Unlike natural teeth, the intra-osseous component of a dental implant is lacking cementum and periodontal ligaments—creating direct contact between the titanium implant and the alveolar bone.16 This junction is the site of osseointegration and the bone that is formed is typically stronger than the surrounding bone.11 Due to the lack of periodontal ligaments, implants in health are ridged in the bone with no mobility.12 What the intra-osseous components provide in ridged stability and strength, the transmucosal component counters with protection from microorganism invasion.

The transmucosal portion provides the biologic seal between the implant and the soft tissue, effectively blocking off microorganisms and inflammatory agents from invading the surrounding tissues.12,16 At the most coronal end, the implant/soft tissue

9 interface of the transmucosal portion starts with the gingival sulcus, which is lined with sulcular epithelium.12 At the base of the gingival sulcus, the long junctional epithelium

(LJE) starts—extending apically while in contact with the titanium implant.12 While there are no connective tissue fiber attachments from the LJE to the titanium implant as with natural teeth and the LJE, the LJE in the transmucosal portion does provide a perimucosal seal for the implant from the external environment.12

Peri-Implant Disease

While the literature concentrates on maintaining healthy dental implants that have osseointegrated and how to maintain them, it is necessary to understand the condition of diseased peri-implant tissues. There are two main peri-implant diseases that occur, peri- implant mucositis and peri-implantitis. Both are similar to diseases of the periodontium for natural teeth—gingivitis and periodontitis.

Peri-implant mucositis is inflammation that is limited to the soft tissues that surround an implant that does not include bone loss around the implant, very similar to gingivitis for natural teeth.18 While peri-implant mucositis is most often caused by excess biofilm, smoking, systemic diseases like diabetes, and retained cement around the prosthesis can also be contributing factors.18 Unlike natural teeth, a periodontal probing depth 4 mm and greater does not necessarily indicate perimucosal inflammation, but could be reflective of a longer abutment style or the final shape of the keratinized tissue—however, bleeding upon gentle probing, increasing pocket depth, and inflamed, erythematous peri-implant tissue are true indicators of peri-implant mucositis.18 A record of periodontal probing depths must be maintained for all dental implant patients so that

10 records can be compared to determine if there is an increase in pocket depth.5,18 Peri- implant mucositis is a threat to the longevity of dental implants and must be recognized and treated to restore health.

Peri-implant mucositis has been reported as high as 40% for patients with dental implants and considerations to treating it is a necessary part of maintaining implants.18

Professional mechanical biofilm removal of the dental implant is the first step in treating peri-implant mucositis and can be accomplished by using specialty ultrasonic scalers with plastic tips, air polishers, implant-safe scalers, or lasers.18 Care needs to be taken to not scratch or alter the surface of the implant or abutment while removing biofilm, calculus or residual cement which could lead to an increase in biofilm retention.18 Chlorhexidine gluconate is the antimicrobial of choice to treat peri-implant mucositis post mechanical biofilm removal.6,18 The patient needs to be made aware of ways that they can improve their homecare so that they may facilitate biofilm removal at home on a daily basis to allow for the resolution of peri-implant mucositis. Finally, the prosthesis around the area of inflammation should be evaluated and a determination should be made if a quality prosthesis was delivered that can be maintained at home by the patient.18 Treating peri- implant mucositis is vital to the success of dental implants.

Peri-implantitis is a serious peri-implant disease affecting 14% of dental implant patients that involves bone loss around the implant with inflamed peri-implant tissues— very similar to periodontitis in natural teeth.18 Clinically, peri-implantitis presents as inflamed gingiva that bleeds upon probing, radiographically evident bone loss around the implant, and increased pocket depths, often with suppuration and redness.18 Peri-

11 implantitis can be caused from untreated periodontitis, smoking, systemic diseases like diabetes, little or no maintenance care, and excess cement on the prostheisis.18 It is crucial to the longevity of dental implants that peri-implantitis be diagnosed and treated expeditiously.

All efforts to treat peri-implantitis aim to remove the underlying infection so that the destruction of the bone that supports the implant stops.18 Typically a combination of improved oral hygiene, non-surgical debridement of the implant/abutment/prosthesis, and surgery to reconstruct the bone/soft tissues is used to treat the infection, sometimes in combination with antibiotics or antiseptics.18 It is sometimes necessary to surgically remove the implant to remove the infection.18 Peri-implantitis is a complex peri-implant disease that typically requires a multi-focal approach.18

Like with periodontal treatments, results are varied in both esthetics and effectiveness when treating peri-implant disease so prevention through home care and professional maintenance is key to a positive long-term outcome.18

Conflicting Treatment Protocols Used in Practice

There has been a documented need for clarity of protocol for both recall and maintenance regimens for dental implant patients.2,4,19 Most previous guidelines were based off of how natural teeth are best maintained or on observational study of dental implant maintenance, possibly explaining why there are so many opposing views for maintaining dental implants.4

In previous years, it was not recommended to probe dental implants and this information has persisted possibly due to being educated prior to routine dental implant

12 placement (before 1990) and/or a lack of continuing education on dental implant maintenance.5 One of the main concerns was that probing implants could damage the delicate biological seal, however gentle probing of implants has been determined to be a safe and efficient way to detect peri-implant disease.20 While the controversy to probe or not to probe has gone on for years, the recommendation to regularly probe dental implants in a gentle manner is currently recommended.2,5,16,18,19 Probing around a healthy dental implant will provide a baseline reading if signs of peri-implant mucositis present during a future maintenance appointment.18

The consensus that evidence-based guidelines needed to be established so that a clear understanding of dental implant maintenance was heard by the American College of

Prosthodontist (ACP) and Clinical Practice Guidelines were published in 2015 after robust research of the topic.4,6

Clinical Practice Guidelines

Clinical practice guidelines (CPG) are evidence-based recommendations of care that have been rigorously researched and extensively discussed by experts in their field and are created so that clinicians have a guide to promote an effective and standardized method of care.6 By understanding and following CPG, dental health care providers can provide optimal care for patients with up to date information that meets today’s standards.21 The American College of Prosthodontists (ACP) convened a panel of experts on dental implant maintenance that was comprised of appointed members from the ACP, the American Dental Association (ADA), the Academy of General Dentistry

(AGD), and the American Dental Hygienists’ Association (ADHA) to discuss and reach a

13 consensus for an evidence-based recommendation of care for dental implant maintenance.6 A CPG for dental implant maintenance of healthy implants, “Clinical

Practice Guidelines for Recall and Maintenance of Patients with Tooth-Borne and

Implant-Borne Dental Restorations”, has since been issued by the ACP, focusing on three main points: recall interval, professional maintenance, and home care for implant maintenance.6 This offers clinicians a guideline for clinical care in the absence of a true standard of care.

CPG for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental

Restorations: Patient Recall Regimen

According to the “Clinical Practice Guidelines for Recall and Maintenance of

Patients with Tooth-Borne and Implant-Borne Dental Restorations” issued by the ACP, dental implants need to be regularly evaluated during recall appointments. Each patient should have a care plan in place that includes the frequency of recall so that there is no confusion regarding evaluation between patient and practitioner, eliminating a scenario where the patient feels that no other steps are necessary after final restoration.6 If a patient has no increased risk of peri-implant disease, then an evaluation of the implants, as well as any remaining natural dentition, should be completed every six months.6 For patients that have been categorized as high-risk for implant failure due to advanced age, lack of ability for home care, compromised natural teeth, or have complex dental restorations, evaluations should be more frequent than every six months, depending on the severity of the individual situation.6 Regular recall will allow for timely professional

14 intervention if a peri-implant problem presents and establishes the timeframe for professional maintenance.

CPG for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental

Restorations: Professional Maintenance Regimen

Professional maintenance is key to the success of the dentition—including both natural teeth and implant borne restorations. Successful professional implant maintenance includes both biological and mechanical factors that need to be addressed for fixed and removable implant prostetics.6 From a biological perspective, a thorough extraoral and intraoral health and dental examination should be performed to evaluate for any finding that falls outside of a healthy parameter.6 Individual oral hygiene instruction should be extensively discussed, including the care of a fixed or removable prosthesis, for efficient biofilm removal.6 Oral hygiene intervention/prophylaxis should be administered to clean any natural teeth, restored teeth, restored implants, or exposed implant abutments.6 In the event that an antimicrobial effect is necessary, professionals should recommend the use of chlorhexidine gluconate as a topical oral solution.6 Regardless of being a fixed or a removable prosthesis, professional maintenance/prophylaxis needs to be applied to it as well. Any removable prosthesis should be cleaned at each recall; however, fixed prosthesis should only be removed and cleaned when warranted due to a lack of necessary home-care.6 If a fixed prosthesis does need removed, new prosthetic screws should be placed and the prosthesis contours should be evaluated for accessibility during home-care.6 The professional maintenance of the biological factors is key to the longevity of dental implants.

From a mechanical perspective, professional implant maintenance requires the inspection of all components of the implant prosthesis and all of its components.6 If any issues are noted, then the adjustment, repair, or replacement of any part that inhibits full function should be completed to ensure no overload of forces nor structural failures allowing biofilm collection occur.6,12,17 Overloading forces on dental implants can lead to failure of the implant due to fracture of the fixture, bone loss from excessive stress to the alveolar bone, or fracturing of the porcelain from the final implant prosthesis.15,17

Individual oral hygiene instruction should be provided to patients regarding any structural challenges that they may face during home-care due to their prosthesis.6 Occlusal devices should be recommended if clinical signs indicate an intervention and the patient should be instructed to wear the device at night.6 By ensuring a professional maintenance regimen, the mechanical perspectives of dental implant care can be evaluated on a regular basis to determine that forces are not overloaded and that the prostheses are accessible for cleaning as recommended at home.

A professional maintenance regimen will provide an opportunity to inspect, repair, and clean the dentition as well as an opportunity to maintain oral health and provide continuity of care. Both the biological and mechanical perspectives need to be addressed regularly to professionally maintain dental implants.

CPG for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental

Restorations: At-Home Maintenance Regimen

The crux of any successful recall program is relaying the importance to the patient that the homecare that they complete on a day-to-day basis is vital to the success of the

16 dental implant. For proper implant maintenance, patients should be instructed to brush any remaining natural teeth and any fixed restorations twice per day with a soft toothbrush with a fluoride toothpaste, as well as how to use appropriate oral hygiene aids, including water flossers, air flossers, interdental cleaners, and electric toothbrushes.6

Instructions for the care of removable prosthesis should be provided if applicable, including twice daily brushing and storing it in an appropriate cleaning solution during sleep. Also, reinforcement of the use of an occlusal guard should be provided if one has been recommended for the patient, making sure to educate the patient on proper cleaning and storage of the splint.6 The utilization of an at-home maintenance regimen will provide invaluable instruction and reinforcement for the overall oral health of the patient.

Clinical Practice Guidelines for dental implant maintenance will allow for a more standardized approach for clinicians to use in their practice in the absence of a standard for care.

The Importance of Dental Implant Maintenance

After the treatment planning, material selection, surgical placement, and final restoration is complete for dental implants, they need to be maintained so that they remain healthy and successful as a prosthesis. Routine dental implant maintenance, including assessment and oral hygiene intervention, has been found to be vital in the long-term prognosis of a successful dental implant.2,3 The need for regular recall, professional maintenance, and the establishment of an at-home maintenance regimen are all part of the realm of dental implant maintenance for healthy dental implants and most of these tasks are completed by dental hygienists in the clinical setting during recall

17 appointments. It is necessary that dental hygienists are well trained on dental implants and how to maintain them.

Significance of the Research

This study is exploratory in nature and will help contribute to the body of knowledge surrounding the education of dental hygienists and where that intersects with dental implant maintenance training. The importance of standardized dental implant maintenance has been established and this research will help determine what student dental hygienists are learning prior to working in the field.6 The purpose of this study was to determine the curricular content for dental hygiene students in the U.S. regarding dental implant maintenance, including what was taught, by whom it was taught, and what sources were utilized regarding dental implant maintenance. This research aimed to find out if the curricular content on implant maintenance in dental hygiene programs aligns with the CPG established by the ACP.

Chapter 2. Materials and Methods

Research Design

This descriptive research study utilized a survey research design to explore the dental implant maintenance curriculum in U.S. dental hygiene programs. Dental hygienists are often the clinicians that are facilitating dental implant maintenance and a knowledge gap has been identified as to what the curricular content was for student dental hygienists regarding dental implant maintenance. Due to the significant range of clinical practices that are used and to fill the identified gap in the literature, this study explored what curriculum was taught to student dental hygienists about dental implant maintenance. This led to the need for an exploratory study to determine the curricular content for entry-level dental hygiene students regarding implant maintenance and the relationship between the curricular content and the existing clinical practice guidelines.

This study was given a status of exempt by the Institutional Review Board of The

Ohio State University (2019E9040). The study involved a survey of program directors of accredited entry-level dental hygiene programs in the United States to determine curricular content regarding dental implant maintenance.

Sample

The survey was emailed to every program director in an accredited dental hygiene program in the U.S, as identified from the American Dental Hygienists’ Association’s

19 website. If the program director position was vacant, the survey was emailed to the individual identified as serving in that capacity.

Instrument

The survey instrument contained 25 total questions and was distributed electronically via the internal email system that Qualtrics utilizes (Appendix A). There was one question procuring informed consent, 22 questions on curricular content of dental implant maintenance procedures, and 2 questions relating to the incentive to participate. The survey was formatted so that participants would be able to complete it on a desktop computer or on a mobile device/tablet.

The survey was pilot tested on five faculty members at The Ohio State University,

Division of Dental Hygiene to establish content validity and reliability. Based on the feedback received, revisions were made to improve the clarity of the questions.

Cronbach’s Alpha statistical analysis was completed and resulted in a reliability coefficient of 0.854.

Procedures

A survey instrument was designed and administered using an online survey management software (Qualtrics; Provo, UT), to determine the curricular content regarding implant maintenance and what resources are being used to teach it for entry- level dental hygiene students. A series of emails were sent to promote completion of the survey. The first email was the initial survey distribution and it included contact information, the purpose of the study, and an invitation for participation. The second email was sent two weeks after the initial survey distribution and was a reminder email to

20 generate additional response, as well as a note of thanks for the participants that either filled out the survey or planned to before close. The third email was sent two weeks after the initial reminder email acting as a final reminder to complete the survey before it closed. The survey was open for five weeks, from mid-October through November 2019.

Data Analysis

Quantitative data was collected to determine the curricular content regarding dental implant maintenance as well as dental hygiene program demographics. All data were stored on Qualtrics secure system to protect accessibility. Prior to statistical analysis, the data were downloaded, and the participants’ responses were de-identified.

Descriptive statistics were used to examine the data using SPSS Version 26 (IBM,

Chicago, Illinois, USA).

Chapter 3. Results

The survey was distributed to 319 potential participants via email, but 47 surveys were undeliverable reducing the sample size to 272 potential participants. There was a total of 53 participants that finished the survey giving a 19.5% response rate (n=53).

Descriptive statistics were conducted to explain the data and the frequencies were determined. Of the 53 survey participants, 36 taught in an Associate or Certificate

Program (67.9%) and 17 taught in a Baccalaureate Program (32.1%). 100% of respondents indicated that they felt having dental implant maintenance as part of their program’s curriculum was important (n=53). When asked how important teaching dental implant maintenance as part of the curriculum is to their program, 90.6% (n=48) reported feeling that it is very important and 9.4% (n=5) reported feeling more aligned with neutral attitude towards importance (Table 1).

Out of the 53 dental hygiene programs that responded, 52 programs taught dental implant maintenance to their students (98.1%). The one program that did not teach dental implant maintenance at the time of the survey indicated that they did not have enough time in their program’s curriculum to teach dental implant maintenance (Table 1).

Descriptive statistics were conducted to determine how many years ago dental implant maintenance curricular content was introduced in the respondent’s dental hygiene program and the frequencies are as follows. Five programs introduced the dental implant

22 maintenance curricular content 1-3 years ago (9.4%). Of the dental hygiene programs surveyed, 15.1% introduced the content 4-6 years ago (n=8). 9.4% of programs introduced the dental implant maintenance curricular content 7-9 years ago (n=5). Of the dental hygiene programs, 20.8% introduced the content 10-12 years ago (n=11). One dental hygiene programs introduced the content 13-15 years ago (1.9%). Of programs that responded, 24.5% introduced the curricular content on dental implant maintenance

16+ years ago (n=13). Ten respondents did not answer the question (18.9%) (Table 1).

When asked if the program directors knew if Clinical Practice Guidelines (CPG) or a standard of care existed for dental implant maintenance, 27 responded yes (50.9%),

24 responded no (45.3%), and 2 did not respond (3.8%). When determining if a CPG was used to create the didactic content of their dental hygiene program, 21 responded yes

(39.6%), 13 responded no (24.5%), 17 responded that they did not know (32.1%), and 2 did not respond (3.8%). When asked if the dental hygiene programs had utilized a CPG when creating the protocols for the dental clinic, 23 responded yes (43.4%), 11 responded no (20.8%), 17 responded that they did not know (32.1%), and 2 did not respond (3.8%)

(Table 2).

Descriptive statistics were conducted to determine what topics were being taught for dental implant maintenance in the didactic portion of dental hygiene programs and the frequencies are as follows. Professional preventative oral care (the removal of plaque biofilm/calculus) for dental implant maintenance was taught in 94.3% of the programs

(n=50). Materials/tools that can be used for dental implant maintenance was taught in

90.6% of the programs (n=48). Implant patient education/home care instruction was

23 taught in 92.5% of the programs (n=49). Radiographic evaluation and subsequent interpretation for dental implants was taught in 88.7% of the programs (n=47). Recall frequency for dental implant patients was taught in 83% of the programs (n=44) (Table

3).

Descriptive statistics were conducted to determine what each program taught didactically to remove biofilm from around an implant and the frequencies were determined. Twenty-five dental hygiene programs taught rubber cup polishing with non- abrasive polishing paste (47.2%). Air polishing with glycine power was taught in 64.2% of the programs (n=34). Twenty-five dental hygiene programs taught the lassoing technique with dental floss (47.2%). Ultrasonic instrument with specialty inserts and plastic tips was taught in 69.8% of the programs (n=37). Forty-nine dental hygiene programs taught using implant scalers to remove biofilm (92.5%). Chlorhexidine gluconate was taught in 1.9% of programs to remove biofilm (n=1) (Table 3).

Descriptive statistics were conducted to determine the frequencies of the type of material that the dental hygiene programs were recommending their students use for implant scalers. Titanium implant scalers were recommended in 77.4% of programs

(n=41). Thirty-six dental hygiene programs recommended plastic implant scalers

(67.9%. Plastic coated with graphite implant scalers were recommended in 11.3% of programs (n=6). Four dental hygiene programs recommended gold implant scalers

(7.5%). Stainless Steel implant scalers were recommended in 3.8% of programs (n=2)

(Table 3).

Descriptive statistics were conducted to determine the frequencies of the type of material that the dental hygiene programs were recommending their students use for implant assessment tools (i.e. periodontal probes). Titanium probes were recommended in 20.8% of programs (n=11). Forty-five dental hygiene programs recommended plastic periodontal probes (84.9%). Stainless steel probes were recommended in 15.1% of programs (n=8). One programs did not allow probes to be used (1.9%) (Table 3).

Descriptive statistics were conducted to determine the frequencies of how often images are recommended by dental hygiene programs for recall patients that have healthy dental implants. Ten programs recommended imaging healthy dental implants in less than six months intervals (18.9%). Taking images every six months was recommended by 7.5% of dental hygiene programs (n=4). Twenty programs recommended imaging healthy dental implants every 12 months (37.7%). Taking images at an interval greater than every 12 months was recommended by 7.5% of dental hygiene programs (n=4).

24.5% of programs had no recommended interval for imaging healthy dental implants

(n=13). Two of the responding programs did not answer this question (3.8%) (Table 4).

Descriptive statistics were conducted to determine the frequencies of how often dental hygiene programs require an exam by the dentist for patients with healthy dental implants. Ten programs recommended having an exam by the dentist more often than every 6 months for patients with healthy dental implants (18.9%). Having an exam with a dentist every 6 months is recommended by 22.6% of dental hygiene programs for patients with healthy dental implants (n=12). Sixteen programs recommended having an exam by the dentist every 12 months for patients with healthy dental implants (30.2%).

Having an exam with a dentist in intervals greater than every 12 months is recommended by 3.8% of dental hygiene programs (n=2). Eleven programs had no set interval for recommending an exam by the dentist for patients with healthy dental implants (20.8%).

Two of the responding programs did not answer this question (3.8%) (Table 4).

Descriptive statistics were conducted to determine the frequencies of how often dental hygiene programs are recommending periodontal probing around healthy dental implants. Twelve programs recommended periodontal probing around dental implants more often than every 6 months (22.6%). Periodontal probing around dental implants was recommended every 6 months by 28.3% of dental hygiene programs (n=15). Six programs recommended periodontal probing around dental implants every 12 months

(11.3%). No programs recommended greater than 12 months (n=0). Seven dental hygiene programs had no standard interval for periodontal probing (13.2%). Two did not answer this question (3.8%) (Table 4).

Descriptive statistics were conducted to determine the frequencies of how often dental hygiene programs were recommending professional preventative care (removal of biofilm/calculus by a dental professional) for patients with healthy dental implants.

Seventeen programs recommended completing the cleaning more often than every 6 months (32.0%). Preventative care was recommended every 6 months by 43.4% of dental hygiene programs (n=23). No programs reported recommending cleanings every

12 months (n=0) or greater than 12 months (n=0). Eleven programs had no standard interval for recommending professional preventative care (20.8%). Two did not answer this question (3.8%) (Table 4).

Descriptive statistics were conducted to determine the frequencies of which year of study dental implant maintenance was taught to entry-level dental hygiene students.

Eight students were taught implant maintenance in their first year (15.1%). Implant maintenance was taught to students in their final year 32.1% of the time (n=17). Twenty- five dental hygiene programs taught dental implant maintenance in each year of study

(47.2%). Three respondents did not answer this question (5.7%) (Table 5).

Descriptive statistics were conducted to determine the frequencies of how many lecture hours are devoted to dental implant maintenance. One dental hygiene program spent less than one hour during lectures on implant maintenance (1.9%). 1-2 hours were spent on dental implant maintenance lectures in 28.3% of programs (n=15). Twenty dental hygiene programs spent 3-4 hours during lectures on implant maintenance

(37.7%). Greater than four hours were devoted to lectures on dental implant maintenance in 26.4% of programs (n=14). Three did not answer this question (5.7%) (Table 5).

Descriptive statistics were conducted to determine the frequencies of what course dental implant maintenance was taught in dental hygiene programs. The curricular content on dental implant maintenance was delivered during didactic basic science courses 75.5% of the time (n=40). Twenty-nine dental hygiene programs delivered the content on implant maintenance during didactic dental hygiene courses (54.7%). The content on dental implant maintenance was delivered during pre-clinic courses 9.4% of the time (n=5). Thirty dental hygiene programs reported teaching dental implant maintenance during Clinic 1 and Clinic 2 (56.6%). The content on dental implant

27 maintenance was delivered during Clinic 3 and Clinic 4 45.3% of the time (n=24) (Table

5).

Descriptive statistics were conducted to determine the frequencies of who taught the curricular content on dental implant maintenance. Periodontists taught the content on implant maintenance 32.1% of the time (n=17). Seven dental hygiene programs had general dentists teach the curricular content on implant maintenance (13.2%). Forty- eight programs had a dental hygienist teach dental implant maintenance (90.6%).

Prosthodontists taught the content on implant maintenance 1.9% of the time (n=1) (Table

5).

Descriptive statistics were conducted to determine the frequencies of what resources/texts were used to develop the curricular content for dental implant maintenance. Twenty-three dental hygiene programs used Clinical Practice for the

Dental Hygienist by Wilkins to develop their content on implant maintenance (43.4%).

In 35.8% of programs, Foundations of Periodontics by Gehrig was used to develop the curricular content (n=19). Periodontology for the Dental Hygienist by Perry was used by

17.0% of dental hygiene programs (n=9). One program used Periodontics: Medicine,

Surgery, and Implants by Rose et al to develop their curricular content (1.9%). Dental

Hygiene: Theory and Practice by Darby and Walsh was used in 20.8% of programs

(n=11). Five programs used Comprehensive Periodontics for the Dental Hygienist by

Weinberg et al (9.4%). Carranza’s Clinical Periodontology by Carranza et al was used in 7.5% of dental hygiene programs (n=4). One program reported using Dental

Radiography: Principles and Techniques by Iannucci (1.9%). Clinical Practice

Guidelines for dental implant maintenance were used in 3.8% of dental hygiene programs

(n=2). Fourteen programs reported using online resources from professional association websites or scholarly articles (26.4%). Two programs used lectures from either a periodontist or a prosthodontist (3.8%) (Table 6).

Chapter 4. Discussion

The purpose of this study was to determine the curricular content for dental hygiene students in the U.S. regarding dental implant maintenance, including what was taught, by whom it was taught, and what sources were utilized regarding dental implant maintenance. Regarding that content, all program directors indicated that they felt that having a curriculum that included dental implant maintenance was important to their program, with almost all of them feeling that it was very important. Only one program reported that they did not teach dental implant maintenance to their dental hygiene students and they indicated that a lack of time was the reason for not including it. With the increasing quantities of dental implants being placed in the U.S, student clinicians will need to be well prepared so that they may provide preventative care for patients with implants.1 With most dental hygiene directors responding that content on dental implant maintenance was very important for their programs and the increasing trend of using implants to restore dentition,7 it is likely that this part of the curriculum will remain

(Table 1).

The following subtopics regarding dental implant maintenance were determined to be of importance. Professional preventative oral care (the removal of calculus and plaque biofilm) is necessary to remove the biological burden from dental implants.6 The utilization of compatible material/tools on dental implants allows for the prosthesis to be 30 maintained without impacting its structural or surface integrity.2,6 Home care instruction for the patient with dental implants is a necessity to ensuring proper biofilm removal at home, limiting the risk of peri-implant disease.2,6 Radiographic evaluation and interpretation of dental implants is a necessary part of dental implant maintenance to identify any undiagnosed bone loss at an early stage.2,22 Overall, most programs surveyed are teaching the identified important subtopics that were identified on the

“Clinical Practice Guidelines for Recall and Maintenance of Patients with Tooth-Borne and Implant Borne Restorations” (Table 3).6

Exam intervals for recall patients that have dental implants are an important part of dental implant maintenance,6 and dental hygiene programs reported a variety of recommendations intervals. Only about one quarter of programs reported recommending a dental exam every 6 months, which aligns with the recommendations issued by the

ACP in the CPG.6 Nearly one third of dental hygiene programs reported recommending a dental exam every 12 months and one fifth of programs have no standard interval for dental exams (Table 4). Nearly three fourths of programs had a recommendation that was outside of the interval advised by the CPG, which could lead to serious complications with dental implants due to lack of evaluation/early intervention.2,6,22

Professional preventative care (removal of calculus and biofilm) recall intervals was identified as an important part of dental implant maintenance.2,6 Dental hygiene programs reported recommending 6 month recalls for preventative care less than half of the time, which is the recommendation issued by the ACP in their CPG (Table 4).6 This leaves the other half of programs either recommending an interval that does not align

31 with the ACP’s recommendations or that the program has no standard interval. A lifelong regimen for maintenance is necessary, and having no standard interval increases the risk that the patient is unaware of the commitment.6

There was some variety in responses for how long the dental hygiene programs had been teaching dental implant maintenance. Almost half of the programs have been teaching about implant maintenance for over a decade, with nearly one quarter of programs teaching implant maintenance for 16+ years and one fifth of programs teaching it for 10-12 years. Nearly one fifth of respondents indicated that they did not know how long the program had been teaching implant maintenance. Roughly one third of the dental hygiene programs had been teaching implant maintenance for less than a decade

(Table 1). With the “Clinical Practice Guidelines for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental Restorations” being published by the

Journal of Prosthodontics in 2015,6 it is possible that some of the programs that had introduced their curriculum on dental implant maintenance prior to that year have not yet incorporated the standardized recommendations that the ACP has published. For future studies, it would be prudent to ask when was the last year that the curricular content for dental implant maintenance was updated to gain further clarification on this topic.

There were multiple resources used to help develop the curricular content for dental implant maintenance in U.S. dental hygiene programs. Eight different textbooks, the ACP’s Clinical Practice Guidelines, professional lectures by a periodontist or prosthodontist, and various online resources were identified as source material (Table 6).

Only a small percentage of dental hygiene programs reported using the ACP’s Clinical

Practice Guidelines to develop their curricular content.

The clinical guidelines that were published by the ACP in 2015 are the closest to a standard of care that dentistry has for implant maintenance. The survey revealed that only half of respondents knew that CPG existed for implant maintenance. Just over one third of dental hygiene programs used the CPG for dental implant maintenance to create the didactic portion of the curriculum. Under half of surveyed dental hygiene programs reported that they used the CPG to create the protocols for their dental clinic (Table 2).

With only half of programs reporting that they knew of the guidelines and well under half using them to create the curricular content for the student hygienists, it is plausible that this is a source that some of the inconsistencies of practices to maintain dental implants stems from.4–6

As previously discussed, just over one third of dental hygiene programs reported using the CPG to create their didactic content (Table 2), however only a very small percentage of dental hygiene programs reporting using the CPG as a resource to develop their programs curricular content (Table 6). While these frequencies appear contradictory, it is possible that educators are not viewing the CPG as a resource material like they view a textbook. Further analysis would be necessary to determine the actions that would be necessary for educators to view the CPG as a resource that they could build their curriculum on dental implant maintenance from.

Limitations

This study had several limitations. At 19.5%, the response rate for this survey was low, limiting the generalizability of the results. Due to the multiple-choice nature of the survey, the participants might not have been able to clarify an answer further to provide a comprehensive view of what their program offers for dental implant maintenance. This research was exploratory in nature and this type of survey design did not allow for causal relationships to be identified. Future studies should focus on causal relationships, allowing for a more definitive direction for improvement of the standardization of curricular content.

Conclusion

Just as the process of implant placement had to be researched and documented over a long span of time, dental implant maintenance needs the same kind of investment.

Being exploratory in nature, this study has helped identify the curricular content for dental implant maintenance in U.S. dental hygiene programs and helped identify where it aligns with the current clinical practice guidelines published by the ACP. This research has identified that most dental hygiene programs in the U.S. are teaching dental implant maintenance but are not utilizing the CPG as a resource to their curricular content. If more programs were to standardize their curricular content based on the current evidence- based recommendations, there would be less variety in clinical settings for dental implant maintenance practices

References

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Appendix A. Tables

TABLE 1. Demographic characteristics of surveyed U.S. Dental Hygiene Programs (n=53)

Type of Program Associates or Certificate Baccalaureate 67.9% (n=36) 32.1% (n=17)

In your program, is Yes No dental implant 98.1% (n=52) 1.9% (n=1) maintenance being taught to the dental hygiene students? How long ago was 1-3 4-6 7-9 10-12 13-15 16 + Missing dental implant Years Years Years Years Years Years maintenance 9.4% 15.1% 9.4% 20.8% 1.9% 24.5% 18.9% procedures introduced (n=5) (n=8) (n=5) (n=11) (n=1) (n=13) (n=10) into your program’s curriculum Do you feel that Yes No having a curriculum 100% (n=53) 0% (n=0) that includes implant maintenance is important? How important do you Very Important Neutral Not Important think it is that your 90.6% (n=48) 9.4% (n=5) 0% (n=0) program teaches information on implant maintenance

TABLE 2. Frequencies Pertaining to Clinical Practice Guidelines (CPG) (n=53) Do you know if CPG or Yes No Missing standard of care for 50.9% 45.3% 3.8% dental implant (n=27) (n=24) (n=2) maintenance exist? Was a CPG used to Yes No Do Not Missing create the didactic Know content of your 39.6% 24.5% 32.1% 3.8% program? (n=21) (n=13) (n=17) (n=2) Was a CPG used to Yes No Do Not Missing create the protocols for Know your clinic? 43.4% 20.8% 32.1% 3.8% (n=23) (n=11) (n=17) (n=2)

TABLE 3. Frequencies of what the curricular content for dental implant maintenance is in dental hygiene programs (n=53) Topics included in the lectures on dental implant maintenance Professional Materials/tools Dental implant Radiographic Preventative preventative that can be patient evaluation of recall frequency oral care for used for education/home dental implants for dental implant implant care instruction and implant patients maintenance maintenance 92.5% (n=49) interpretation 83.0% (n=44) 94.3% 90.6% (n=48) 88.7% (n=47) (n=50) Biofilm removal techniques taught for dental implants Rubber cup Air Lassoing Ultrasonic Compatible Chlorhexidine polishing polishing technique instrument Implant gluconate rinse with with with floss w/plastic Scalers 1.9% (n=1) polishing glycine 47.2% tip 92.5% paste powder (n=25) 69.8% (n=49) 47.2% 64.2% (n=37 (n=25) (n=34) Material that the implant scalers are made from that the students are advised to use Titanium Plastic Plastic w/ Gold Stainless Steel 77.4% 67.9% (n=36) graphite 7.5% (n=4) 3.8% (n=2) (n=41) 11.3% (n=6) Material that the implant assessment tools (probes) are made from that the students are advised to use Titanium Plastic Stainless Steel No Probes Allowed 20.8% (n=11) 84.9% (n=45) 15.1% (n=8) 1.9% (n=1) *% may total to greater than 100% due to multiple choices being selected.

TABLE 4. Frequencies for the recall intervals that dental hygiene programs recommended their students follow Recommended imaging interval for healthy dental implants that students are advised to use <6 Months 6 Months 12 Months >12 Months No Standard Missing 18.9% 7.5% (n=4) 37.7% 7.5% (n=4) 24.5% 3.8% (n=10) (n=20) (n=13) (n=2) Recommended dental exam interval for patients with healthy dental implants <6 Months 6 Months 12 Months >12 Months No Standard Missing 18.9% 22.6% 30.2% 3.8% (n=2) 20.8% 3.8% (n=10) (n=12) (n=16) (n=11) (n=2) Recommended interval for periodontal probing on patients with healthy dental implants <6 Months 6 Months 12 Months >12 Months No Standard Missing 22.6% 28.3% 11.3% (n=6) 0% (n=0) 13.2% (n=7) 3.8% (n=12) (n=15) (n=2) Recommended interval for professional preventative care on patients with healthy dental implants <6 Months 6 Months 12 Months >12 Months No Standard Missing 32.0% 43.4% 0% (n=0) 0% (n=0) 20.8% 3.8% (n=17) (n=23) (n=11) (n=2)

TABLE 5. Frequencies of dental hygiene program timing and course type for dental implant maintenance training (n=53) What year are dental 1st Year Final Year Both Years Missing hygiene students taught about implant 15.1% (n=8) 32.1% 47.2% 5.7% (n=3) maintenance? (n=17) (n=25) How many lecture hours <1 Hour 1-2 3-4 >4 Missing are devoted to dental Hours Hours Hours implant maintenance? 1.9% 28.3% 37.7% 26.4% 5.7% (n=3) (n=1) (n=15) (n=20) (n=14) Who teaches the lecture Periodontist General Dental Prosthodontist on dental implant Dentist Hygienist maintenance? 32.1% 13.2% 90.6% 1.9% (n=17) (n=7) (n=48) (n=1) During what courses are Didactic Didactic Pre- Clinic Clinic dental implant Basic Dental Clinic 1 & 2 3 & 4 maintenance procedures Science Hygiene taught? Course Course 75.5% 54.7% 9.4% 56.6% 45.3% (n=40) (n=29) (n=5) (n=30) (n=24)

*% may total to greater than 100% due to multiple choices being selected.

TABLE 6. Frequencies for Resources used to develop curricular content (n=53) What resources did your program use to develop the curricular content for dental implant maintenance lectures? Clinical Practice Foundations of Periodontology for Periodontics: of the Dental Periodontics, the Dental Medicine, Surgery, Hygienist, Wilkins Gehrig Hygienist, Perry et & Implants, Rose 43.4% (n=23) 35.8% (n=19) al. et al. 17% (n=9) 1.9% (n=1 Dental Hygiene: Comprehensive Carranza’s Clinical Dental Theory and Periodontics for the Periodontology, Radiography: Practice, DH, Weinberg et Carranza et al. Principles and Darby/Walsh al. 7.5% (n=4) Techniques, 20.8% (n=11) 9.4% (n=5) Iannucci 1.9% (n=1) Clinical Practice Online Resources: Lecture by Guidelines, Bidra Prof Association/ Periodontist or et al. Websites/Articles Prosthodontist 3.8% (n=2) 26.4% (n=14) 3.8% (n=2) *% may total to greater than 100% due to multiple choices being selected

Appendix B. Survey

Survey

1. Please provide your consent to participate in the study. If you do not give consent, please stop and close your web browser now. a. Yes, I consent to participating in the study b. No, I do not consent (Close web browser now)

2. What kind of dental hygiene program are you in? a. Certificate b. Associate c. Baccalaureate

3. Do you feel that having a curriculum that includes information on dental implant maintenance is necessary or important for your institution? a. Yes b. No

4. How important do you think it is for your institution to offer information on dental implant maintenance? a. Very important b. Neutral c. Not Important

5. In your curriculum, do you teach implant maintenance procedures to your dental hygiene students? a. Yes b. No

6. If no implant maintenance procedures are taught to dental hygiene students, please indicate the most influential factor for the omission? a. Lack of curriculum time b. Lack of financial resources c. Lack of qualified faculty d. Concerns that it should not be included in undergraduate curriculum e. Other, please specify ______f. Not applicable

7. If yes, what year are they taught implant maintenance procedures? a. 1st Year b. 2nd Year c. 3rd Year d. Not applicable

8. If yes, how long ago was implant maintenance procedures introduced to your curriculum? a. 1-3 years b. 4-6 years c. 7-9 years d. 10-12 years e. 13-15 years f. 16 or over years

9. During what class is implant maintenance procedures taught? a. Didactic Basic Science Course b. Didactic Dental Hygiene Course c. Pre-Clinic d. Clinic I or Clinic II e. Clinic III or Clinic IV f. Other, please specify ______

10. Who teaches the class on implant maintenance? a. Periodontist b. General Dentist c. Dental Hygienist d. Other, please specify ______

11. How many lecture hours are devoted to dental implant maintenance? a. <1 hour b. 1-2 hours c. 3-4 hours d. >4 hours e. Not applicable

12. Which of the following topics are included in the lecture series? Please select all that apply. a. Professional preventative oral care for implant maintenance b. Materials/tools that can be used for implant maintenance c. Implant patient education/at home instruction d. Radiographic evaluation of implants and subsequent interpretation e. Recall Frequency

13. What textbooks, resources, or guidelines do your program use to develop the curricular content for dental implant maintenance, please include all sources. - ______

14. What does your clinic teach to remove biofilm around an implant? Choose all that apply. a. Rubber cup polishing with non-abrasive polishing paste b. Air polishing with glycine powder c. Lassoing technique with floss d. Ultrasonic with specialty insert and plastic tip e. Implant Scalers f. Other, please specify ______

15. What material are your implant maintenance scalers made from? Choose all that apply. a. Titanium b. Plastic c. Plastic Coated with Graphite d. Gold e. Stainless Steel f. Other, please specify ______

16. What material are your implant assessment tools made from (i.e. probes)? a. Titanium b. Plastic c. Gold d. Stainless Steel 49

e. Other, please specify ______

17. What is the interval that your program advises students to image healthy dental implants for recall patients? a. Every 12 months e. No Standard Interval

18. How often do you require an exam by a dentist for implant recall patients? a. Every 12 months e. No Standard Interval

19. How often do you recommend professional preventative care for implant recall patients? a. Every 12 months e. No Standard Interval

20. How often does your program recommend periodontal probing around an implant? a. Every 12 months e. No Standard Interval

21. Do you know if a Clinical Practice Guideline (CPG) or standard of care exists for Dental Implant Maintenance? a. Yes b. No

22. Did your dental hygiene program utilize a Clinical Practice Guideline for Dental Implant Maintenance when deciding the didactic portion of the curriculum on dental implant maintenance? a. Yes b. No c. Do Not Know

23. Did your dental hygiene program utilize a Clinical Practice Guideline for Dental Implant Maintenance when deciding your clinical protocols? a. Yes b. No c. Do Not Know

24. Thank you for your participation in this survey. Would you like to participate in the $100.00 Visa Gift Card Give Away? One survey participant that completes the survey will be selected at random. a. Yes b. No

25. In the event that you are selected to receive the gift card, please provide your full name and mailing address.

a. ______