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Oral Health Maintenance of Dental Implants

Connie M. Kracher, PhD, MSD; Wendy Schmeling Smith, RDH, BSEd


Continuing Education Units: 2 hours

Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.

In recent years, the demand for dental implants has risen greatly. Not only have techniques improved, but the benefits that implants provide patients have increased as well. Dental implants can improve appearance, confidence, and self-esteem; preserve remaining teeth; improve a persons ability to speak and masticate properly; and eliminate the need for full and partial dentures.

Conflict of Interest Disclosure Statement ADA CERP

The authors report no conflicts of interest associated with this work. The Procter & Gamble Company is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: http://www.ada.org/cerp

Approved PACE Program Provider

The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2009 to 7/31/2013. In recent years, the demand for dental implants has risen greatly. Osseointegrated dental implants are being placed with increased frequency. It is estimated that approximately 1 million dental implants are placed in the United States annually. Not only have placement techniques improved, but the benefits that

Overview

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implants provide for patients have increased as well. Dental implants improve appearance, confidence, and self-esteem. Implants also preserve remaining teeth, improve a persons ability to speak and masticate properly, and eliminate the need for full and partial dentures. Because dental implants present a significant financial investment and require long-term maintenance by the patient for a healthy periimplant environment, the direct impact of oral hygiene maintenance by the patient will determine long-term prognosis and success of the dental implant. The mucoperiosteal-implant seal is the major factor in determining long-term prognosis. Indigenous oral bacteria attaching to dental implant surfaces can lead to the breakdown of the biological seal surrounding the dental implant. Although the junctional epithelium attachment for dental implants is similar to natural dentition, the connective tissue interface with the dental implant has poor mechanical resistance. The periimplant disease process resembles periodontitis. However, treatment and maintenance are more complex. The tissues around dental implants react to bacteria similarly to the tissues around natural teeth. In fact, plaque develops more rapidly and in larger amounts around titanium implant abutments than around natural teeth. Therefore, close cooperation and teamwork among dental providers and their patients is essential to the success of dental implant procedures. Many of the current home care treatments for periodontal maintenance of natural teeth also can be used with dental implants, but a better understanding of oral health maintenance by the patient is crucial for the health and longevity of dental implants. Upon completion of this course, the dental professional should be able to: Understand the importance of oral hygiene maintenance as it applies to the success rate for implants. Describe the different uses of auxiliary aids and antimicrobial rinses. Explain the correct usage of an oral irrigator around implants. List the components of a clinical assessment during recare visits. Discuss the usage of metal instruments on the implant surfaces

Learning Objectives

Course Contents

Glossary Preventive Maintenance Patient Self Care Manual and Power Toothbrushing Auxiliary Aids and Antimicrobial Rinses Clinical Maintenance Procedures Debridement Conclusion Course Test References About the Authors

cytotoxic Destructive to cells. embrasure V-shaped space between the proximal surfaces of adjacent teeth. fibroblast Cell that develops connective tissue. galvanic Of or relating to direct-current electricity, especially when produced chemically; also having the effect of an electric shock. junctional epithelium Cufflike band of stratified squamous epithelium continuous with the sulcular epithelium encircling the tooth providing a seal at the base of the sulcus. osteolytic Pertaining to the loss of bone. osseointegration Attachment of healthy bone to an implant. pellicle Thin coating of salivary materials that are deposited on tooth surfaces. peri- prefix: Around or surrounding (for example, perioral means surrounding the mouth). 2

Glossary

antimicrobial Destroying or preventing the development of microorganisms; also, an agent with such activity. bacteremia Introduction of bacteria to the bloodstream. bacteriostasis Inhibition of bacterial growth without destruction. crevicular Pertaining to a crevice, particularly the gingival crevice.

Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 6, 2013

pontic An artificial tooth. radiolucent Allowing radiation to pass through, presenting as a dark area on a radiograph. substantivity A property of certain active ingredients that inhibits growth of bacteria on the skin and other body tissues.

Preventive Maintenance

Studies indicate when multiple oral hygiene devices are prescribed, patients can become discouraged and as a result, may be less motivated. However, research shows additional plaque inhibition with a combination of toothbrushing, auxiliary aids, and antimicrobial mouthrinses. For this reason, it is important to consider appropriate combinations when making recommendations to individual patients. Manual and Power Toothbrushing Various types of toothbrushes may be used to clean implant superstructures. Exposed facial and lingual areas of the dental implant, its fixed and/or removable prosthesis, and surrounding gingival tissues can be cleaned using a soft, multitufted, nylon toothbrush. There are many different brush handle angles from which to choose. The dental professional should assist the patient in choosing a handle that allows the patient to successfully access all areas of the oral cavity. The modified Bass technique should be used, or a short, horizontal back-and-forth movement can be employed. In the modified Bass technique, the brush is held at a 45-degree angle where the abutment post meets the gingival tissue (Figures 1 & 2). Patient toothbrushing techniques often miss cleaning the most lingual aspect of the titanium abutment cylinders, so patients must be instructed to give special attention to the lingual aspects. Rotary, uni-tufted power brushes (Figure 3), oscillating-rotating brushes (Figure 4) and sonic brushes (Figure 5) do not damage polished implant surfaces and also can be safely used to clean the facial, lingual, and interproximal areas of the implant. Many power brushes are equipped with soft interchangeable bristle heads (flattened, rubber-cup-like, short and long pointed in shape). The short and long pointed tips are ideal for reaching proximal areas of the tooth, those areas

If the titanium oxide layer of the dental implant is disrupted during oral hygiene procedures, the soft tissues may be exposed to titanium metallic ions that can cause potentially cytotoxic reactions compromising the dental implant. Therefore, detailed instructions by the dental professional should be given initially to the patient and reinforced at each recare appointment to prevent trauma or infection to the sulcus around the implant. The removal of early microbial accumulation on the dental implant surfaces and the elimination of at least 85% of plaque biofilm by the patient are crucial for long-term peri-implant success. The preventive maintenance steps for dental implants involve two distinct aspects: (1) patient self care, and (2) clinical maintenance procedures. Patient Self Care No single device has been shown to remove plaque from all surfaces of an implant reconstruction. While there are numerous types of brushes, threading systems, flosses, and other oral hygiene devices on the market, the literature substantiates the need to minimize the number of devices prescribed for patient self care. Patient compliance, an essential aspect of any maintenance program, predominantly depends upon the relative simplicity of a procedure, the time required, and a minimum number of devices being employed.

Figure 1.

Figure 2. Modified Bass Technique

Courtesy of medical-dictionary.thefreedictionary.com

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Figure 3. Rotadent
Courtesy of Zila, Inc.

Figure 4. Oral-B

Courtesy of Crest Oral-B

Figure 5. Sonicare

Courtesy of Philips Sonicare

Figure 6. Proxabrush Interdental System


Courtesy of Sunstar Americas, Inc.

with wide embrasures, and those areas located beneath the pontic portion of a fixed bridge. The hollowed, rubber cup should be used on the facial and lingual aspects of the implant and adjacent teeth. The brush tip should be dipped in a 0.12% solution of chlorhexidine gluconate (i.e., Zila Pharmaceuticals Peridex or Colgates PerioGuard). Research associated with the utilization of this solution shows a reduction in certain bacteria by 54-97% after six months use. The very fine bristles of the Rotadent simultaneously debride the implant surface and deliver the antimicrobial solution to the crevicular area. One oral hygiene implant study examined the Rotadent and the Proxabrush Interdental System (manual interproximal cleaning aids from the Sunstar Americas, Inc.) (Figure 6). Results demonstrated virtually no change in surface appearance from the original machined implant and its surface irregularities. 4

Auxiliary Aids and Antimicrobial Rinses In certain situations, interproximal brushes with small brush heads such as a Sunstar Americas GUM End-tuft (Figure 7) may be necessary to gain easier access. However, such devices must be plastic-coated because metal can damage or contaminate an implants titanium surface. An interdental brush (Figure 8) can be used to massage the gingival tissue around an implant to increase blood flow and enhance the tone of the surrounding gingiva. The patient should be instructed to insert the tip interdentally in an occlusal direction, pressing the side of the tip against the marginal gingiva and applying a gentle rotary motion. Oral-B Super Floss (Figure 9), a wide band of ribbon with one end designed for use as a threading device, can be threaded around

Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 6, 2013

Figure 10. Postcare

Courtesy of Sunstar Americas, Inc.

Figure 7. GUM End-tuft Brush

Courtesy of Sunstar Americas, Inc.

Figure 8. Oral-B Interdental Brush

Courtesy of Crest Oral-B

Figure 11. Floss threader

Figure 9. Oral-B

Courtesy of Crest Oral-B

abutments and beneath frameworks. Especially designed for implant care, Super Floss or Postcare by Sunstar Americas, Inc. (Figure 10) can be used in conjunction with chlorhexidine gluconate. Used in the manner of a shoe-shine rag (i.e., a side-to-side motion), the ribbon polishes the back and sides of the post from top to bottom. This cleansing action produces positive results for plaque control around fixtures and abutment cylinders, as well as the cervical aspect. In areas with smaller interfixtural dimension, traditional unwaxed floss may be used with a floss threader (Figure 11). The oral irrigator is a beneficial adjunct for removing supragingival soft debris around implants. However, caution must be exercised by the patient when using this device. Incorrect use and excessive water pressure can damage 5

the junctional epithelium, leading to bacteremia. To prevent these problems, patients must receive instruction to use the lowest water-pressure setting. Furthermore, patients are educated to place the irrigator tip in the interproximal area horizontal to the implant and along its gingival margin to avoid subgingival spray. An oral rinse containing chlorhexidine gluconate or phenolic compounds (Listerine, Johnson & Johnson) may be used as an irrigant. Microbial plaque plays a major role in both adult periodontitis and peri-implantitis. Similar microbial flora are found around the gingival crevices of both adult periodontal disease and failing implants. The regular use of chemotherapeutic agents such as antiseptic mouthrinses may be recommended to the dental implant patient to combat these concerns. Chlorhexidine gluconate is a safe, nontoxic adjunct to other oral hygiene procedures in the maintenance of dental implants. An American Dental Association-accepted chlorhexidine

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gluconate mouthrinse can be very effective due to its substantivity (binding activity to the tissues in the oral cavity and on titanium abutment surfaces). Treating implant patients with chlorhexidine gluconate mouthrinses aids in fibroblast attachment to implant surfaces. The acquired pellicle acts as a chemical reservoir source, releasing chlorhexidine gluconate over a prolonged period of time in concentrations sufficient to maintain bacteriostasis. About 90% of the cultivable bacteria are inhibited for about five hours with a 0.12% concentration of chlorhexidine gluconate rinsing for 30 seconds. Because staining of composites often accompanies long-term use of chlorhexidine gluconate rinses, it can be applied with a cotton swab when composite restorations are present. Patients should be advised that chlorhexidine gluconate use also can diminish taste sensation for salty foods. Peridex and PerioGard have no effect on the dental implant surface itself. It may be safe to assume that other antimicrobial agents such as phenolic compounds (Listerine and Crest Pro-Health) also produce no surface alteration. As an oral rinse, application is recommended once daily with a chlorhexidine gluconate formulation or twice daily with most over-the-counter therapeutic rinses. Auxiliary aids such as angled brushes, floss threaders, sulcular brushes, Stim-U-Dent Interdental Cleaners (Johnson & Johnson), the Postcare flossing aid, and irrigation devices are all alternative secondary mechanical plaquecontrol aids, but again, limiting the number of devices is important for patient compliance. Disclosing solutions and tablets are a valuable aid in revealing the presence of plaque to the implant patient. Inspection of disclosed areas assists the patient in identifying areas of plaque retention and provides immediate feedback on the effectiveness of oral hygiene procedures. Clinical Maintenance Procedures At each recare visit, the dental professional should perform a clinical assessment of periimplant soft tissues by examining the color, surface texture, and note any bleeding and inflammation. When probing, the use of a nonmetal periodontal probe will not contaminate the titanium surface, is gentle to tissue, and safe 6

against dental implant surfaces. Some clinical researchers suggest that periodontal probing be performed at infrequent intervals at one site (the same site each time) with light pressure. As with natural dentition, the dental professional must be careful not to contaminate the implant sulcus with bacteria from a diseased periodontal sulcus. It is recommended that the periodontal probe be dipped in chlorhexidine between measurements to avoid contaminating a healthy site with microflora from a diseased site. Although 3 mm is considered healthy for natural dentition, probing depths for implants can range from 2.5-5 mm depending on soft tissue depth, as the probe goes beyond the sulcus, through the junctional epithelial attachment and connective tissues, placing it closer to the alveolar bone. As a rule, the ideal sulcus depth should be less than 5 mm, as sulcus depths greater than 5-6 mm have a potential for anaerobic bacteria. Increased probing depths have been correlated with failing implants; 58% of failing implants are characterized by pocket depths greater than 6mm. The worldrenowned Brnemark Group found that an average marginal bone loss of 1.5 mm occurred during the first year of prosthesis connection and an average of 0.1 mm every year thereafter. Any bone loss exceeding these averages should raise concern. The major difference between gingival attachment to a natural tooth and a dental implant is that the implant surface lacks cementum with connective tissue fiber inserts. Gingivitis most likely progresses to periodontitis around the implant due to the unreliability of the perimucosal seal and the lack of fiber barriers between the implant and the soft tissue of the sulcus. When examining the implant, the dental professional must chart the presence of plaque and calculus deposits around the implant surfaces. The bacteria responsible for periodontitis are the same for peri-implantitis. These pathogenic bacteria are gram-negative anaerobic bacteria, including: Bacteroides forsythus, actinobacillus actinomycetemcomitans, porphyromonas gingivalis, and Treponema denticola shown to contribute to failing implant sites. After the soft tissue has been examined, the next step is to evaluate mobility of the implants, transmucosal abutments, and prosthetic

Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 6, 2013

superstructure. Seventy-eight percent of failing implants have excess mobility. Mastication or lack of tissue stability at the junction of the dental implant and connective tissue can cause apical migration of the junctional epithelium which in turn causes gingival recession, alveolar bone loss, and pocketing. The occlusion should be monitored at recare appointments to detect occlusal changes. Possibly the most important evaluation tool to evaluate the health and success of the implant is dental radiographic images. It is the most reliable of all the conventional periodontal indices for evaluating failing implants. A mobile implant may display a narrow, radiolucent space surrounding the implant-bone interface. Radiographic images can assess bone height and density and show the functional relationship between the prosthesis, implant, and abutment components. It is suggested that radiographic images (excluding the baseline radiographic image taken one week post-surgery) be taken every three months after initial placement of the implant. After the first year, radiographic images should be taken once each year. In the last few years, cone beam computed tomography (CBCT) has been used for measuring cortical bone thickness, as well as being utilized in post-operative imaging. However, recent studies acknowledge its limitations such as overestimating the vertical distance between the top of the implant and the crestal bone.

Conventional metal curettes, as well as sonic and ultrasonic scalers, cause considerable changes to the implant surface. Only instruments made of plastic, graphite, nylon, or those with a Tefloncoating should be in contact with the implant. The use of a dissimilar metal (such as stainless steel) on titanium may lead to corrosion. The use of these dissimilar metals on implant surfaces have been studied in vitro, comparing the number of human gingival fibroblasts attaching to the surface of a commercially pure titanium-alloy curette. Results showed a significant reduction in the number of fibroblasts attaching to titanium implants that had been scaled with the stainlesssteel curette when compared to the plastic and titanium scalers. Ultrasonic instrumentation continues to be contraindicated with dental implants. Ultrasonic scalers may severely disrupt the titanium dioxide surface, leading to a multitude of grooves and a roughened surface, which can lead to further plaque retention and a compromised implant. A study utilizing a modified ultrasonic instrument with a custom-designed delvin plastic tip showed that the standard ultrasonic instrument caused considerable scratching and gouging to the titanium implant. Shallow scratches made with the metal ultrasonic could be polished smooth, but the deeper scratches could not. The modified ultrasonic instrument produced noticeable but minimal changes that when polished did not appear to be microscopically different from the polished control. The modified ultrasonic instrument may be a promising device for maintenance of the dental implant. No definite answer can be made concerning ultrasonic use for implants at this time. Although air polishing on implant surfaces was controversial in the past, recent studies have shown air polishing to be effective and safe for maintenance procedures. After calculus deposits have been removed, the prosthesis and abutments may be selectively polished with a rubber cup and a nonabrasive fine polishing paste. Rubber cup polishing alone appears to be the least abrasive treatment using a prophylaxis paste, commercial implant pastes, or tin-oxide. However, paste deposits will be left on the implant surfaces. A rubber point may also 7

Debridement

In addition to regular self-care procedures, a periodic, professional oral prophylaxis is required to maintain a healthy oral environment. Professional dental prophylaxis is essential in every periodontal maintenance case. For dental implant plaque and calculus removal, only instruments that do not damage the implant surfaces may be used. In commercial use and form, pure titanium is soft, non-magnetic, and passive. These metallic surfaces develop a layer of titanium oxide that does not undergo any further breakdown under physiologic situations. Damage can lead to changes in the surface chemistry of the material, resulting in corrosion. Surface roughness and corrosion facilitate plaque retention, ultimately compromising the implant. It is therefore imperative that no oral health maintenance procedure directly affect this titanium oxide surface layer.

Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 6, 2013

be used. After polishing, the implant surfaces should be gently irrigated with water to avoid any adverse tissue healing. An antimicrobial solution should be applied to the peri-implant tissues. If a dental implant is displaying increased probing depths, bleeding, or any other indication of the onset of failure, a controlled drug delivery system, such as Arestin by OraPharma, Inc., can be applied. These systems contain a tetracyclineloaded fiber that is designed to slowly release the antibiotic over a ten-day period. The fibers can be used in single or multiple sites and may provide additional benefits to conventional scaling and root planing. A strict prophylaxis recare schedule should be established and maintained to monitor the oral health findings in dental implant patients. The patient is often seen for comprehensive oral hygiene instructions and soft-tissue examination within the first week after the prosthesis is placed. A follow-up visit is scheduled for one month later. At this appointment, the clinician reviews the adequacy of self care procedures and re-evaluates the health of the peri-implant tissues. After the one month follow-up, a three-

month recare schedule is suggested for a one-year duration. Depending on patient self care and the individuals periodontal status, the patient may then be placed on a six-month recare schedule after the first year. During the first two years, no more than six months should elapse between recare visits.

Conclusion

The dental professionals role is to determine the dental implant patients individual and specific self care needs. Recommendations and instructions to patients are often determined by the prosthesis design, location and angulation of the implants, the length and the position of the transmucosal abutments, and other factors such as patient habits (i.e. smoking,) motivation to perform consistent self care and the patients manual dexterity. It is important to recommend individualized auxiliary aids to gain and maintain appropriate self care and compliance. To ensure optimal peri-implant health, the patient must maintain daily biofilm removal and maintain regular professional care. To achieve long-term success, it is important to maintain a prophylaxis recare schedule at which evaluations are performed to assess gingival, bone, and implant health.

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Course Test Preview

To receive Continuing Education credit for this course, you must complete the online test. Please go to www.dentalcare.com and find this course in the Continuing Education section. 1. _______________ is the major factor in determining long-term prognosis of the dental implant. a. The mucoperiosteal-implant seal b. Using the high-speed handpiece during the procedure c. The frequency of professional recare visits d. Using power toothbrushes The peri-implant disease process resembles periodontitis. The dental implant can be compromised if the titanium oxide layer of the implant is disrupted. a. Both statements are true. b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false. Plaque develops more __________ and in __________ amounts around titanium implant abutments than around natural teeth. a. slowly / smaller b. rapidly / smaller c. rapidly / larger d. slowly / larger _______________ has been shown to best remove plaque from all surfaces of an implant. a. Brushes b. Floss c. Threading systems d. No single technique Studies indicate that when multiple oral hygiene devices are prescribed, at one time, the patient _______________. a. may become discouraged and less motivated b. may become more motivated and encouraged c. overly zealous with home care d. overwhelmed and stop self care completely The _______________ technique is the preferred toothbrushing method for dental implants. a. Fones b. Modified Bass c. Modified Stillman d. Charters When cleaning an implant, oral hygiene auxiliary devices, including scalers and periodontal probes, should be _______________. a. metal to remove all debris from implant b. made from same material as the implant c. plastic coated d. titanium

2.

3.

4.

5.

6.

7.

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Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 6, 2013

8.

The oral irrigator may be utilized with caution on dental implants as incorrect use or excessive water pressure can lead to damage of the junctional epithelium and cause _______________. a. bacteremia b. bacteriostasis c. osteolytic d. osseointegration The mouthrinse containing _______________ aids in the fibroblast attachment to implant surfaces. a. chlorhexidine gluconate b. phenolic compound c. plant alkaloids d. tetracycline

9.

10. Gingivitis around dental implants most likely progresses to periodontitis due to _______________. a. the unreliability of the perimucosal seal b. the lack of fiber barriers between the implant and the soft tissue of the sulcus c. lack of patient knowledge d. A and B 11. As a rule, the ideal sulcus depth around a dental implant should be no more than _______ mm. a. 2 b. 2.5 c. 5 d. 6 12. The most important evaluation tool and the most reliable method to determine implant failure is _______________. a. mobility b. radiographs c. probing depths d. tissue tone 13. Ultrasonic instrumentation should ____________ be used with dental implants. a. never b. usually c. always d. rarely 14. If an implant is displaying increased probing depths, bleeding, or other indications of the onset of failure, the clinician should _______________. a. have the patient step up home care maintenance to three times a day b. remove the implant before more damage is done c. apply a controlled drug delivery system d. see the patient on a weekly basis until condition is under control

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15. A strict prophylaxis recare schedule should be established and maintained to monitor oral health findings in implant patients, and no more than __________ month(s) should elapse between oral hygiene/recare visits. a. one b. three c. twelve d. six 16. An increase of dental implants has risen greatly due to _______________. a. improved placement techniques b. improved speech and mastication c. improved patient confidence and self esteem d. All of the above. 17. The _______________ is/are crucial for long-term peri-implant success. a. removal of early microbial accumulation b. elimination of at least 85% of plaque biofilm c. prophylaxis recare schedule to assess gingiva and bone health d. All of the above. 18. Treatment of both adult periodontitis and peri-implantitis may begin with effective microbial plaque removal and _______________. a. surgical removal of any inflamed tissue b. yearly in-office prophylaxis c. regular use of chemotherapeutic mouthrinses d. regular use of systemic medication 19. A 30 second rinse of 0.12 percent concentration of chlorhexidine can inhibit _______ percent of the cultivable bacteria for approximately _______ hours. a. 90 / 5 b. 80 / 4 c. 70 / 3 d. 60 / 2 20. To ensure optimal peri-implant health, the dental professional must determine the patients individual and specific self care needs, such as _______________. a. habits such as smoking b. oral health motivation c. manual dexterity d. All of the above.

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References

1. American Academy of Periodontology. Maintenance and Treatment of Dental Implants [position paper], April 1995. 2. Iacono VJ, Committee on Research, Science and Therapy, American Academy of Periodontology. Dental implants in periodontal therapy. J Periodontol. 2000 Dec;71(12):1934-1942. 3. Bauman GR, Mills M, Rapley JW, Hallmon WW. Implant maintenance: debridement and peri-implant home care. Compendium. 1991 Sep;12(9):644, 646, 648. 4. Balshi TJ. Hygiene maintenance procedures for patients treated with the tissue integrated prosthesis (osseointegration). Quintessence Int. 1986 Feb;17(2):95-102. 5. Biesbrock AR, Bartizek RD, Gerlach RW, Terzhalmy GT. Oral hygiene regimens, plaque control, and gingival health: a two-month clinical trial with antimicrobial agents. J Clin Dent. 2007;18(4): 101-105. 6. Babbush CA et al. Dental Implants. The Art and Science, 2nd Edition. Saunders: Maryland Heights, MO, 2011. 7. Becker W, Becker BE, Newman MG, Nyman S. Clinical and microbiologic findings that may contribute to dental implant failure. Int J Oral Maxillofac Implants. 1990 Spring;5(1):31-38. 8. Branemark, Zarb, Albrektson. Tissue-Integrated Prosthesis Osseointegration in Clinical Dentistry. Chicago; Quintessence, 1985, p. 14-25. 9. Brough Muzzin KM, Johnson R, Carr P, Daffron P. The dental hygienists role in the maintenance of osseointegrated dental implants. J Dent Hyg. 1988 Oct;62(9):448-453. 10. Dmytryk JJ, Fox SC, Moriarty JD. The effects of scaling titanium implant surfaces with metal and plastic instruments on cell attachment. J Periodontol. 1990 Aug;61(8):491-496. 11. Fox SC, Moriarty JD, Kusy RP. The effects of scaling a titanium implant surface with metal and plastic instruments: an in vitro study. J Periodontol. 1990 Aug;61(8):485-490. 12. Friedman LA. Oral hygiene for dental implant patients. Tex Dent J. 1991 May;108(5):21-23, 29. 13. James RA. Peri-implant considerations. Dent Clin North Am. 1980 Jul;24(3):415-420. 14. Kawashima H, Sato S, Kishida M, Yagi H, Matsumoto K, Ito K. Treatment of titanium dental implants with three piezoelectric ultrasonic scalers: an in vivo study. J Periodontol. 2007 Sep;78(9):1689-1694. 15. Koumjian JH, Kerner J, Smith RA. Implants: hygiene maintenance of dental implants. Ill Dent J. 1991 Jan-Feb;60(1):54-59. 16. Kracher CM. Peri-implant Postoperative Treatment Considerations to Prevent Peri-implantitis. World Dental 3:17-19, May-June 2011. 17. Kracher CM. Continuing Education: Current Concepts in Preventive Dentistry. American Dental Assistants Association. 2012. 18. Kwan JY, Zablotsky MH, Meffert RM. Implant maintenance using a modified ultrasonic instrument. J Dent Hyg. 1990 Nov-Dec;64(9):422, 424-425, 430. 19. Meffert RM. The soft tissue interface in dental implantology. J Dent Educ. 1988 Dec;52(12):810-811. 20. Mioduski TE Jr, Guinn NJ. Dental implants. Permanent replacement for lost teeth. AORN J. 1990 Mar;51(3):729-737. 21. Misch CE. Contemporary Implant Dentistry, 3rd Edition. Mosby: St. Louis, MO, 2008. 22. Nimmons KJ. The Expanding Esthetic Practice: Implant Maintenance - Part 2. Comp Esthetics & Restor Prac May 2005;2-5. 23. Orton GS, Steele DL, Wolinsky LE. Dental professionals role in monitoring and maintenance of tissueintegrated prostheses. Int J Oral Maxillofac Implants. 1989 Winter;4(4):305-310. 24. Papaspyridakos P, Chen CJ, Singh M, et al. Success criteria in implant dentistry: a systematic review. J Dent Res. 2012 Mar;91(3):242-248. 25. Rapley JW, Swan RH, Hallmon WW, Mills MP. The surface characteristics produced by various oral hygiene instruments and materials on titanium implant abutments. Int J Oral Maxillofac Implants. 1990 Spring;5(1):47-52. 26. Ramaglia L, di Lauro AE, Morgese F, Squillace A. Profilometric and standard error of the mean analysis of rough implant surfaces treated with different instrumentations. Implant Dent. 2006 Mar;15(1):77-82. 12
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27. Rasmussen RA. The Branemark System of Oral Reconstruction. 1992; A Color Atlas. Kyiyaku EuroAmerica, Inc. 28. Razavi T, Palmer RM, Davies J, Wilson R, Palmer PJ. Accuracy of measuring the cortical bone thickness adjacent to dental implants using cone beam computed tomography. Clin Oral Implants Res. 2010 Jul;21(7):718-725. 29. Renvert S, Lessem J, Dahln G, et al. Topical minocycline microspheres versus topical chlorhexidine gel as an adjunct to mechanical debridement of incipient peri-implant infections: a randomized clinical trial. J Clin Periodontol. 2006 May;33(5):362-369. 30. Sato S, Kishida M, Ito K. The comparative effect of ultrasonic scalers on titanium surfaces: an in vitro study. J Periodontol. 2004 Sep;75(9):1269-1273. 31. Taylor TD. Dental Implants: Are They for Me? 1993; Quintessence Books, 2nd edition. 32. Van Orden AC. Corrosive response of the interface tissue to 316 L stainless steel, titanium based alloy, and cobalt based alloys. In: McKinney RV, Lemons JE (eds) The Dental Implant: Clinical and Biological Response of Oral Tissues. PSG, Littleton, MA, USA, 1985, 1-24. 33. Vehemente VA, Chuang SK, Daher S, Muftu A, Dodson TB. Risk factors affecting dental implant survival. J Oral Implantol. 2002;28(2):74-81. 34. Van Steenberghe D. Periodontal aspects of osseointegrated oral implants modum Brnemark. Dent Clin North Am. 1988 Apr;32(2):355-370. 35. Wilkins EM, Wyche C. Clinical Practice of the Dental Hygienist, 10th edition. Philadelphia:Lippincott Williams & Wilkins, 2009.

About the Authors


Connie M. Kracher, PhD, MSD Dr. Kracher is an Associate Professor of Dental Education, Director of the Dental Assisting Program, and the Chair of the Department of Dental Education at Indiana University - Purdue University, Fort Wayne. She holds a PhD from Lynn University in Boca Raton, Florida, a Master of Science in Dentistry from the Indiana University School of Dentistry in Oral Biology, and a Bachelor of Science from Indiana University Purdue University Indianapolis. In addition to her CDA, she holds a Certificate in Expanded Restorative Procedures (EFDA). Dr. Kracher is a frequent contributor to the Dental Assistant Journal and is the author of four ADAA courses: Sports Related Dental Injuries & Sports Dentistry, Blood Pressure Guidelines and Screening Techniques and Current Concepts in Preventive Dentistry. Email: kracher@ipfw.edu Wendy Schmeling Smith, RDH, BSEd Wendy Schmeling Smith received her baccalaureate degree in education from Indiana University Purdue University Indianapolis. She is a licensed dental hygienist in private practice in Indianapolis, Indiana.

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