Research Assessment and Maintenance of Dental Implants: Clinical and Knowledge– Seeking Practices of Dental Hygienists

Sue Tucker Ward, RDH, MEd; Charlene A. Czuszak, DDS, MS; Ana Luz Thompson, RDH, MHE; Mary C. Downey, RDH, MS; Marie A. Collins, RDH, MS, EdD

Introduction Abstract Dental implants have become the Purpose: This study surveyed dental hygienists in order to treatment of choice for replacing assess their routine approach for maintenance missing teeth, and the frequency and to determine if a relationship exists between the formal of placement has rapidly increased education of dental hygienists and their previous attendance since the mid–1960s.1 Varying re- and interest in future implant related continuing education sults have been reported in studies courses. related to assessing dental implants, identifying signs of failure, planning Methods A survey was distributed to dental hygienists at- continued care, implementing treat- tending an annual national continuing education course. Par- ment and evaluating outcomes.2–5 ticipants voluntarily completed and submitted their survey Researchers have expounded on before the end of the first day of the 3 day course. various protocols for the assessment Results: The results indicate that there is a statistically sig- of dental implants, which include nificant relationship between the level of formal education obtaining radiographs and assessing and implant related continuing education course attendance. periodontal health (probing depths, Dental hygienists whose formal education did not include mobility, and dental implant care were more likely to attend implant re- inflammation).6,7 After systematic lated continuing education courses than those whose formal reviews of randomized controlled education included this content. The majority of the dental trials, Faggion et al developed an hygienists expressed interest in continuing education courses evidence–based algorithm for the on dental implants. Results of chi–square analysis show a treatment of peri–implantitis.4 statistically significant relationship between the type of edu- cation and interest in attending implant related continuing It is widely known that bleeding education courses. There was no statistically significant dif- on probing is an indicator of inflam- ference in continuing education interest between dental hy- mation of soft tissue whether around gienists whose formal education did or did not include dental natural teeth or implants. However, implants. there is controversy regarding the Conclusion: Additional continuing education courses have frequency of probing around den- been completed by most dental hygienists whose curricula tal implants due to risk of damag- did not include formal training on dental implant care. Most 5 ing delicate peri–implant tissues. dental hygienists are interested in gaining additional knowl- Another concern is introducing bac- edge whether or not their dental hygiene curriculum con- teria into peri–implant tissues from tained content on dental implants. surrounding teeth for which Terra- ciano suggests avoiding cross con- Keywords: Dental implants, dental hygienists, oral examina- tamination by probing and scaling tion, instrumentation, dental continuing education dental implants first.2 Overall, re- This study supports the NDHRA priority area, Clinical Dental searchers agree that gentle probing Hygiene: Assess the use of evidence–based treatment rec- is an important part of the implant ommendations in dental hygiene practice. recall.2,5,7,8

The use of plastic probes is recommended to provide more flexibility when positioning it parallel produce less damage to the implant surface and to to the long axis of the abutment.2,9 For the most

104 The Journal of Dental Hygiene Vol. 86 • No. 2 • Spring 2012 gentle probing around dental implants, a plastic scores improved in both groups, with no effects controlled–force probe is recommended.10 on probing depths15 • Resin tipped scalers versus gold coated or Heitz–Mayfield described best practices for de- graphite instruments: resin tipped scalers do tecting implant failure using mobility tests and ra- not create scratches and performed better than diographic findings.11 Radiographs are deemed an gold coated/graphite instruments16 integral component of implant maintenance and • Plastic scalers versus ultrasonic device: plastic the most important assessment tool for evaluat- scalers produced less alteration of titanium sur- ing implant status.6,12 The literature varies as to faces than ultrasonic device17 the recommended interval for taking radiographs. • Curettes versus ultrasonic device: no group dif- Recommended maintenance protocols distinguish ferences in the ability to reduce the microbiota necessary care during and after the first year of in peri–implantitis3 implant placement. A few of the various protocols • Ultrasonic scalers covered with a plastic sheath suggested are: and Ultrasonic scalers with carbon tips versus metal scalers: carbon and plastic tipped ultra- • Initial placement: 6 months, 12 months and sonics produced smooth implant surfaces while every 2 years12,13 metal tips resulted in damaged implant surfac- • Initial placement: 1, 3 and 5 years if no pathol- es18 ogy present5 • Initial placement: 6 and 12 months, annually Dental hygienists are routinely responsible for if no pathology present – if pathology present, the continuity of patient education and maintenance every 6 months until resolution14 of dental implants, years beyond initial placement. This care is referred to as the “first line” therapy Panoramic radiographs are most valuable when or the nonsurgical approach.4 However, there is a determining potential implant candidates.2 Radio- paucity of evidence based research regarding the graphs can be used to determine bone loss over best practices for implant maintenance, specifically time, to identify areas of radiolucency that could by the dental hygienist. Graduates prior to the late indicate implant failure, and to confirm adequate 1990s may have had little to no formal education seating of the abutment or prosthesis.2,5,8,9,11,12 Pe- on implant care, yet they are treating patients with riapical radiographs using the paralleling technique dental implants. Dentists are encouraged to active- have been recommended to assess bone loss and ly seek standardized and comprehensive training implant components.5 When evaluating dental im- via professional–centered education.4 Professional plants after placement, panoramic radiographs continuing education may similarly fulfill this need are considered helpful tools by some while others for dental hygienists. question their value.5,13 In this current study, authors surveyed dental The dental hygiene appointment may include de- hygienists from diverse educational and practice bridement of hard and soft deposits using hand and backgrounds in order to assess their routine ap- power instruments designed specifically to protect proach for dental implant maintenance. This study the delicate implant surface. Recare intervals of 3, also sought to determine if a relationship exists 4 or 6 months are recommended for careful evalu- between the formal education of dental hygienists ation of peri–implant tissues by the dental hygien- and their previous attendance and interest in fu- ist and dentist.8 ture continuing education courses about implants.

Persson pointed out that it is likely that the in- Methods and Materials struments available for around im- After an extensive review of the literature, fac- plants are not properly designed to reach affected ulty at the Medical College of Georgia Department areas.3 This limitation is mentioned because im- of Dental Hygiene developed a 24–item paper plant design, location and clinical conditions make survey specifically for this study. All items on the it difficult to provide adequate debridement of survey reflected content found in publications that dental implants. While searching for ideal implant addressed maintenance of dental implants. Only tools, researchers have studied the effect of sev- the faculty considered the questions and content eral debridement instruments on implant surfaces. validity of the survey. The protocol for this study Summaries of their findings include: was submitted to the institution’s Human Assur- ance Committee. Upon review of the proposal, it • Titanium hand instruments versus ultrasonic was determined that this study was not considered scalers: no group differences were found in human subjects research as defined by the federal the treatment outcomes. Plaque and bleeding regulations because the data obtained was restrict-

Vol. 86 • No. 2 • Spring 2012 The Journal of Dental Hygiene 105 ed to assessing the practices of dental hygienists. Table I: States Where Participants Practice Dental Hygiene Upon arrival to an annual national continuing education course, the instrument Dental Hygiene State Number % Care of Implants–Survey of Dental Hygienists was GA 277 75 distributed to all attendees (n=370). All course SC 43 12 attendees were female and the states they rep- NC 19 5.1 resented are shown in Table I. Participants were conveniently sampled and volunteered to submit FL 17 4.6 their survey before the end of the first day of the VA 2 0.5 3 day course. Surveys submitted after the first day KY 2 0.5 of the symposium were not included in this study because lectures on implant maintenance were MD 1 0.3 scheduled for the second day. Completed surveys NJ 1 0.3 were returned to the continuing education staff TN 6 1.6 members before the data collection deadline. Data were entered in a spreadsheet by 1 author and OH 1 0.3 then independently verified by another author to IL 1 0.3 ensure accuracy. Total 370 100 Results Table II: Dental Implant Training and Survey response rate was 57.5% (n=213). Continuing Education Most dental hygienists (n=170, 80%) reported employment in a general practice setting, fol- n % lowed by 7% (n=14) in periodontal practice. The Received training in classroom and 25 12 remaining 13% (n=27) reported working in oth- clinic on implant care while attending er settings which included pediatric, endodontic dental hygiene school and government entities. One hundred and five (49%) reported that they have practiced for over Did not receive any training on implant 108 51 15 years, while 38 (18%) have practiced 11 to care while attending dental hygiene 15 years and 66 (31%) have practiced 10 years school or less. Attended one or more continuing 111 52 education courses on implant Table II details dental implant training, history maintenance of continuing education and interest of the partic- Has not attended continuing education 100 47 ipants in future continuing education courses on courses on implant maintenance dental implants. Half of the participants reported that they received formal training on dental im- Interested in a continuing education 198 93 plants during their dental hygiene education and course to strengthen background in about half reported that they did not receive such maintenance of dental implants training. A chi–square test was used to deter- Not interested in a continuing education 12 5.6 mine if there is a relationship between the type course to strengthen background in of education (formal education versus no formal maintenance of dental implants education) and continuing education course at- tendance (attended course versus did not attend p=0.88). Most dental hygienists (n=199, 93.9%) course). The results indicate that there is a sta- expressed interest in continuing education cours- tistically significant relationship between the type es on dental implants. of education and continuing education course attendance (chi–square with 1 degree of free- A summary of the survey responses regard- dom=5.435, p=0.019). Dental hygienists whose ing procedures for dental implant maintenance is formal education did not include dental implant shown in Tables III through VII. Table III summa- care were more likely to attend continuing educa- rizes responses regarding the clinical assessment tion courses than those whose formal education of dental implants. Over 90% (n=193 to 198) of included this content. There was no statistically participants reported that they evaluate plaque/ significant difference in continuing education in- deposits, exudate/bleeding, mobility terest between dental hygienists whose formal and inflammation. Fewer (n=67, 31%) evaluate education did or did not include dental implants the presence of salivary percolation around the (chi–square with 1 degree of freedom=0.021, margin of crowns covering implants. The major-

106 The Journal of Dental Hygiene Vol. 86 • No. 2 • Spring 2012 Table III: Clinical Assessment of Dental Implants Table IV: Radiographic Assessment of Dental Implants n % Evaluates amount of adjacent 104 49 n % keratinized tissue Takes radiographs of an implant 117 55 Evaluates color of adjacent gingival 193 91 once a year tissue (inflammation present) Takes radiographs of an implant 28 13 Evaluates presence of stippling/tissue 133 62 every 6 months consistency Takes radiographs of an implant 12 5.6 Evaluates presence of 196 92 every 3 months during the 1st exudate/bleeding year and every 6 months thereafter Evaluates presence of deposits (plaque 198 93 and/or calculus) Takes radiographs of an implant 20 9.4 every 3 months during the 1st Evaluates presence of salivary 67 31 year and annually thereafter percolation when slight pressure is applied to the crown of an implant Takes radiographs of an implant at a 9 4.2 different established interval Evaluates mobility 195 92 Takes radiographs of an implant at 32 15 Evaluates occlusion 113 53 no set interval Evaluates parafunctional habits 121 57 Uses other intervals for scheduling 12 5.6 (grinding, abrasion) implant patients for maintenance Evaluates recession 173 81 after the first year of completion Probes around implants 162 76 Routinely takes periapical 147 69 Does not probe around implants 39 18 radiographs of implants Uses plastic probe 149 70 Routinely takes vertical bitewing 48 23 radiographs of implants Uses metal probe 17 8 Routinely takes horizontal bitewing 50 23 Uses pressure–sensitive plastic probe 9 4.2 radiographs of implants Uses automated probe 0 0 Routinely takes panoramic 31 15 Records the presence of bleeding on 153 72 radiographs of implants probing around the implant Does not routinely take radiographs 12 5.6 Does not record the presence of bleeding 14 6.6 of implants on probing around the implant Checks bone level surrounding 178 84 Establishes a fixed reference point 98 46 the implant on a regular basis at such as the margin of a crown to use maintenance appointments during probing Does not check bone level 27 13 Does not establish a fixed reference 65 31 surrounding the implant on a point such as the margin of a crown to regular basis at maintenance use during probing appointments ity of respondents probe around dental implants hygienists (n=151, 71%) do not dip the probe in (n=162, 76%) and use a plastic probe (n=149, an antimicrobial agent prior to using it to evalu- 70%). In Table IV, over half (n=117, 55%) take ate dental implants. Almost half (n=97, 45.5%) radiographs of dental implants at least once per administered a microbial rinse and half do not year, and 69% (n=147) reported periapicals as (n=107, 50%). the most common type of radiograph taken. Maintenance intervals for patients with dental In Table V, dental hygienists most commonly implants are reported in Table VII. Most respon- reported that they perform both supragingival dents (n=166, 77%) indicated that they schedule and subgingival instrumentation around dental patients every 3, 4 or 6 months during the first implants (n=164, 77%). Most (n=190, 89%) use year after completion of the dental implant. Forty plastic scalers during debridement, while a few percent (n=86) reported that, after the first year (n=16, 7.5%) use stainless steel scalers on den- of placement, maintenance intervals are primar- tal implants. As shown in Table VI, most dental ily based on individual need.

Vol. 86 • No. 2 • Spring 2012 The Journal of Dental Hygiene 107 Discussion Table V: Implementation of Dental Hygiene Care Plan The date of gradua- tion from their dental n % hygiene program may Has an established protocol in office for home care instructions 130 61 explain why over half of for implant patients the participants in this Does not have an established protocol in office for home care 75 35 study did not receive instructions for implant patients formal training on dental implant maintenance. Performs supragingival instrumentation around implants 39 18 Dental implants may Performs subgingival instrumentation around implants 7 3.3 not have been part of Performs both supragingival and subgingival instrumentation 164 77 their curriculum. Hum- around implants phrey notes that dental Uses stainless steel scalers during debridement around implants have now be- 16 7.5 come an integral part implants of dental reconstruction Uses plastic scalers during debridement around implants 190 89 and quotes that ap- Uses graphite scalers during debridement around implants 26 12 proximately 300,000 to Uses teflon coated scalers during debridement around implants 22 10 428,000 dental implants are placed annually in Uses gold–tipped scalers during debridement around implants 8 3.8 the U.S.5 Accordingly, it Uses ultrasonic scalers with standard inserts during 13 6.1 is imperative that den- debridement around implants tal hygienists have the Uses ultrasonic scalers with specific implants during 25 12 most current knowledge debridement around implants for the maintenance of Uses other type of instruments during debridement around dental implants. 10 4.7 implants The majority of par- Uses fine prophy paste for polishing the implant/crown 80 38 ticipants surveyed in this Uses medium prophy paste for polishing the implant/crown 44 21 study follow the recom- mendations of Kurtzman Uses tin oxide for polishing the implant/crown 7 3.3 during visual inspection Uses air polisher for polishing the implant/crown 40 19 of tissues surrounding Uses toothpaste for polishing the implant/crown 25 12 dental implants, noting Uses prophy paste designed for implants for polishing the color, texture, amount 17 8 implant/crown of biofilm and calculus, probing depths, bleed- Uses other agents for polishing the implant/crown 16 7.5 ing, mobility and reces- Polishes the implant post if it is visible 91 43 sion.8 Most reported they Does not polish the implant post if it is visible 105 49 probe dental implants. Although probing causes a separation between the surface of the implant and In this study, most dental hygienists used plastic the , it is still deemed an indis- scalers as recommended in the literature.2,9,10 How- pensable part of implant maintenance.7 ever, a few participants reported that they use metal scalers and ultrasonic scalers with standard inserts. About 5% (n=11) reported they dip the probe in Periodic evaluation of the dental implant is critical an antimicrobial rinse prior to use on dental implants to the health of peri–implant tissues. Participants in to avoid cross–contamination. However, there has this study indicated they follow the traditional 3 to 6 not been any substantial evidence to validate the ef- month re–care interval. This finding correlates with fectiveness of this approach. Fifty percent (n=107) the recommended 3 month re–care intervals during reported use of an antimicrobial rinse as part of their the first year after implant placement and continuous implant care protocol, although current evidence does supervision of the patient with implants.5,9 There is not show a significant difference between debride- a paucity of refereed evidence based research that ment alone and debridement with antimicrobials.19,20 specifically addresses the care of implants by the The frequency of taking radiographs varied amongst dental hygienist. Accordingly, Hultin suggests that participants in this study, which is consistent with the there is a need for such studies to be initiated.21 variety of protocols suggested in the literature.5,12–14 Results of this study cannot be generalized to

108 The Journal of Dental Hygiene Vol. 86 • No. 2 • Spring 2012 the entire population of Table VI: Use of Antimicrobials dental hygienists due to n % the limitations of using Dips the probe in an antimicrobial rinse prior to use on im- a convenience sample. 11 5.2 Further studies should plants include a sample that Does not dip the probe in an antimicrobial rinse prior to use on 151 71 is representative of the implants 130,000 active dental Uses an antimicrobial rinse as part of implant care protocol 97 45.5 hygienists in the U.S.22 Does not use an antimicrobial rinse as part of implant care The popularity of dental 107 50 implants will continue protocol to increase with the ag- Uses antimicrobial rinse as part of implant care 83 39 ing population who will protocol demand more esthetic Uses essential oils antimicrobial rinse as part of implant care 43 20 care. Thus, dental hy- protocol gienists will continue Uses cetylpyridinium chloride antimicrobial rinse as part of to be the first line of 15 7 implant care protocol therapy in maintaining healthy peri–implant tis- Uses other antimicrobial rinse as part of implant care protocol 7 3 sues. Uses antimicrobial as pre–rinse 60 28 Conclusion Uses antimicrobial as oral irrigation 49 23 This study provided Uses antimicrobial as a dip for floss/gauze 11 5 a descriptive summary Uses antimicrobial as a dip for the probe 8 4 of knowledge–seeking practices and clinical Table VII: Maintenance Intervals approaches used by dental hygienists in the n % maintenance of dental Schedules implant patients for maintenance once during the 1 0.5 implants. Over half of first year after placement the participants in this Schedules implant patients for maintenance every 3 months study did not have for- 73 34 during the first year after placement mal training on dental Schedules implant patients for maintenance once every 4 implants during their 22 10 dental hygiene educa- months during the first year after placement tion, but have taken Schedules implant patients for maintenance once every 6 71 33 continuing education months during the first year after placement courses. Regardless of No established policy for scheduling implant patients for main- 37 17 whether they had for- tenance during the first year mal training or not, Uses other intervals for scheduling implant patients for mainte- most dental hygienists 14 6.6 are interested in gain- nance during the first year ing additional knowl- Schedules implant patients annually for maintenance after the 6 2.8 edge regarding dental first year of completion implants. Schedules implant patients every 3 months for maintenance 31 15 after the first year of completion Sue Tucker Ward, Schedules implant patients every 6 months for maintenance RDH, Med, is an associ- 80 38 after the first year of completion ate professor, Depart- Schedules implant patients based on individual need for main- ment of Dental Hygiene. 86 40 Charlene A. Czuszak, tenance after the first year of completion DDS, MS, is an assistant professor, Department professor, Department of Dental Hygiene. Marie A. of Dental Hygiene, and assistant professor, Depart- Collins, RDH, MS, EdD, is a professor and depart- ment of Oral Health & Diagnostic Sciences, College ment chair, Department of Dental Hygiene, College of Dental Medicine. Ana Luz Thompson, RDH, MHE, of Allied Health Sciences and Acting Associate Dean. is an associate professor, Department of Dental Hy- All currently work at the College of Allied Health Sci- giene. Mary C. Downey, RDH, MS, is an associate ences, Georgia Health Sciences University.

Vol. 86 • No. 2 • Spring 2012 The Journal of Dental Hygiene 109 References

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