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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 person’s 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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Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 6, 2013
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Therefore. particularly the gingival crevice. Dental implants improve appearance. the connective tissue interface with the dental implant has poor mechanical resistance. improve a person’s ability to speak and masticate properly. osteolytic – Pertaining to the loss of bone. The tissues around dental implants react to bacteria similarly to the tissues around natural teeth. especially when produced chemically. peri. the direct impact of oral hygiene maintenance by the patient will determine long-term prognosis and success of the dental implant. Crest Oral-B at dentalcare. close cooperation and teamwork among dental providers and their patients is essential to the success of dental implant procedures. Implants also preserve remaining teeth. Revised March 6. • 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. In fact. “perioral” means “surrounding the mouth”). Although the junctional epithelium attachment for dental implants is similar to natural dentition. Indigenous oral bacteria attaching to dental implant surfaces can lead to the breakdown of the biological seal surrounding the dental implant. The mucoperiosteal-implant seal is the major factor in determining long-term prognosis. • Describe the different uses of auxiliary aids and antimicrobial rinses. plaque develops more rapidly and in larger amounts around titanium implant abutments than around natural teeth. osseointegration – Attachment of healthy bone to an implant. • Explain the correct usage of an oral irrigator around implants. Many of the current home care treatments for periodontal maintenance of natural teeth also can be used with dental implants. Upon completion of this course. 2013 ® ® . However. and self-esteem. pellicle – Thin coating of salivary materials that are deposited on tooth surfaces. • List the components of a clinical assessment during recare visits. treatment and maintenance are more complex. the dental professional should be able to: • Understand the importance of oral hygiene maintenance as it applies to the success rate for implants. fibroblast – Cell that develops connective tissue. 2 Glossary antimicrobial – Destroying or preventing the development of microorganisms.– prefix: Around or surrounding (for example.implants provide for patients have increased as well. 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. Because dental implants present a significant financial investment and require long-term maintenance by the patient for a healthy periimplant environment. an agent with such activity. bacteremia – Introduction of bacteria to the bloodstream. and eliminate the need for full and partial dentures. embrasure – V-shaped space between the proximal surfaces of adjacent teeth. also. bacteriostasis – Inhibition of bacterial growth without destruction.com Continuing Education Course. but a better understanding of oral health maintenance by the patient is crucial for the health and longevity of dental implants. confidence. crevicular – Pertaining to a crevice. The periimplant disease process resembles periodontitis. also having the effect of an electric shock. galvanic – Of or relating to direct-current electricity.

the literature substantiates the need to minimize the number of devices prescribed for patient self care. In the modified Bass technique. predominantly depends upon the relative simplicity of a procedure. substantivity – A property of certain active ingredients that inhibits growth of bacteria on the skin and other body tissues. or a short. rubber-cup-like. The preventive maintenance steps for dental implants involve two distinct aspects: (1) patient self care. short and long pointed in shape). For this reason.thefreedictionary. Preventive Maintenance Studies indicate when multiple oral hygiene devices are prescribed. threading systems. Figure 1. Patient compliance. auxiliary aids. the time required. Many power brushes are equipped with soft interchangeable bristle heads (flattened. may be less motivated. it is important to consider appropriate combinations when making recommendations to individual patients. the soft tissues may be exposed to titanium metallic ions that can cause potentially cytotoxic reactions compromising the dental implant. and surrounding gingival tissues can be cleaned using a soft. Rotary. There are many different brush handle angles from which to choose. and antimicrobial mouthrinses. Patient Self Care No single device has been shown to remove plaque from all surfaces of an implant reconstruction. presenting as a dark area on a radiograph. The short and long pointed tips are ideal for reaching proximal areas of the tooth. and a minimum number of devices being employed. uni-tufted power brushes (Figure 3).pontic – An artificial tooth. While there are numerous types of brushes. Revised March 6. The modified Bass technique should be used. Patient toothbrushing techniques often miss cleaning the most lingual aspect of the titanium abutment cylinders. Therefore. flosses. Exposed facial and lingual areas of the dental implant. Manual and Power Toothbrushing Various types of toothbrushes may be used to clean implant superstructures. 2013 ® ® . and other oral hygiene devices on the market. and (2) clinical maintenance procedures. an essential aspect of any maintenance program. nylon toothbrush. patients can become discouraged and as a result. 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. research shows additional plaque inhibition with a combination of toothbrushing.com Continuing Education Course. 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 brush is held at a 45-degree angle where the abutment post meets the gingival tissue (Figures 1 & 2). its fixed and/or removable prosthesis.com 3 Crest Oral-B at dentalcare. 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. and interproximal areas of the implant. Modified Bass Technique Courtesy of medical-dictionary. radiolucent –Allowing radiation to pass through. multitufted. horizontal back-and-forth movement can be employed. The dental professional should assist the patient in choosing a handle that allows the patient to successfully access all areas of the oral cavity. However. Figure 2. so patients must be instructed to give special attention to the lingual aspects. those areas If the titanium oxide layer of the dental implant is disrupted during oral hygiene procedures. lingual.

) (Figure 6).” 4 Auxiliary Aids and Antimicrobial Rinses In certain situations. Inc. The brush tip should be dipped in a 0. Inc. Rotadent® Courtesy of Zila.Figure 3. a wide band of ribbon with one end designed for use as a threading device. 2013 ® ® . One oral hygiene implant study examined the Rotadent® and the Proxabrush Interdental System® (manual interproximal cleaning aids from the Sunstar Americas. However. Figure 4. Inc. Oral-B® Courtesy of Crest Oral-B Figure 5. Results demonstrated “virtually no change in surface appearance from the original machined implant and its surface irregularities. The hollowed. such devices must be plastic-coated because metal can damage or contaminate an implant’s titanium surface. and those areas located beneath the pontic portion of a fixed bridge. Zila Pharmaceuticals’ Peridex® or Colgate’s PerioGuard®). with wide embrasures. Proxabrush® Interdental System Courtesy of Sunstar Americas. Oral-B Super Floss® (Figure 9)..com Continuing Education Course. Sonicare® Courtesy of Philips Sonicare Figure 6. Revised March 6. can be threaded around Crest Oral-B at dentalcare. The very fine bristles of the Rotadent® simultaneously debride the implant surface and deliver the antimicrobial solution to the crevicular area. pressing the side of the tip against the marginal gingiva and applying a gentle rotary motion.e. rubber cup should be used on the facial and lingual aspects of the implant and adjacent teeth. The patient should be instructed to insert the tip interdentally in an occlusal direction. Research associated with the utilization of this solution shows a reduction in certain bacteria by 54-97% after six months use. interproximal brushes with small brush heads such as a Sunstar Americas GUM® End-tuft (Figure 7) may be necessary to gain easier access.12% solution of chlorhexidine gluconate (i. 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.

Postcare® Courtesy of Sunstar Americas. Similar microbial flora are found around the gingival crevices of both adult periodontal disease and failing implants. Microbial plaque plays a major role in both adult periodontitis and peri-implantitis. Incorrect use and excessive water pressure can damage 5 the junctional epithelium. In areas with smaller interfixtural dimension. Inc. An oral rinse containing chlorhexidine gluconate or phenolic compounds (Listerine®. 2013 ® ® . as well as the cervical aspect.e. Chlorhexidine gluconate is a safe. nontoxic adjunct to other oral hygiene procedures in the maintenance of dental implants.Figure 10. traditional unwaxed floss may be used with a floss threader (Figure 11). Figure 7. Inc. The regular use of chemotherapeutic agents such as antiseptic mouthrinses may be recommended to the dental implant patient to combat these concerns. However. a side-to-side motion). Super Floss® or Postcare® by Sunstar Americas. To prevent these problems. This cleansing action produces positive results for plaque control around fixtures and abutment cylinders. Johnson & Johnson) may be used as an irrigant. Used in the manner of a “shoe-shine rag” (i. Oral-B® Interdental Brush Courtesy of Crest Oral-B Figure 11. Furthermore. Revised March 6. The oral irrigator is a beneficial adjunct for removing supragingival soft debris around implants. An American Dental Association-accepted chlorhexidine Crest Oral-B at dentalcare. Figure 8. caution must be exercised by the patient when using this device. patients must receive instruction to use the lowest water-pressure setting.com Continuing Education Course. 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. leading to bacteremia. GUM® End-tuft Brush Courtesy of Sunstar Americas. Oral-B® Courtesy of Crest Oral-B abutments and beneath frameworks. Especially designed for implant care.. Inc. the ribbon polishes the back and sides of the post from top to bottom. (Figure 10) can be used in conjunction with chlorhexidine gluconate. Floss threader Figure 9.

The worldrenowned Brånemark Group found that an average marginal bone loss of 1. The acquired pellicle acts as a chemical reservoir source. 58% of failing implants are characterized by pocket depths greater than 6mm. and note any bleeding and inflammation. Clinical Maintenance Procedures At each recare visit. As a rule. Because staining of composites often accompanies long-term use of chlorhexidine gluconate rinses. As an oral rinse. About 90% of the cultivable bacteria are inhibited for about five hours with a 0. and safe 6 against dental implant surfaces. is gentle to tissue.com Continuing Education Course. It may be safe to assume that other antimicrobial agents such as phenolic compounds (Listerine® and Crest Pro-Health®) also produce no surface alteration. 2013 ® ® . Revised March 6. Treating implant patients with chlorhexidine gluconate mouthrinses aids in fibroblast attachment to implant surfaces. The bacteria responsible for periodontitis are the same for peri-implantitis. Inspection of disclosed areas assists the patient in identifying areas of plaque retention and provides immediate feedback on the effectiveness of oral hygiene procedures. it can be applied with a cotton swab when composite restorations are present. Peridex® and PerioGard® have no effect on the dental implant surface itself. probing depths for implants can range from 2. 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. the dental professional must chart the presence of plaque and calculus deposits around the implant surfaces. including: Bacteroides forsythus. the next step is to evaluate mobility of the implants. application is recommended once daily with a chlorhexidine gluconate formulation or twice daily with most over-the-counter therapeutic rinses. as sulcus depths greater than 5-6 mm have a potential for anaerobic bacteria. surface texture. floss threaders. 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. When probing. porphyromonas gingivalis. the dental professional should perform a clinical assessment of periimplant soft tissues by examining the color. As with natural dentition. as the probe goes beyond the sulcus. the Postcare® flossing aid.5-5 mm depending on soft tissue depth.5 mm occurred during the first year of prosthesis connection and an average of 0. Auxiliary aids such as angled brushes. placing it closer to the alveolar bone. the ideal sulcus depth should be less than 5 mm. through the junctional epithelial attachment and connective tissues. the dental professional must be careful not to contaminate the implant sulcus with bacteria from a diseased periodontal sulcus. Stim-U-Dent® Interdental Cleaners (Johnson & Johnson). Disclosing solutions and tablets are a valuable aid in revealing the presence of plaque to the implant patient. Patients should be advised that chlorhexidine gluconate use also can diminish taste sensation for salty foods. and Treponema denticola shown to contribute to failing implant sites.1 mm every year thereafter.12% concentration of chlorhexidine gluconate rinsing for 30 seconds. 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. When examining the implant. These pathogenic bacteria are gram-negative anaerobic bacteria. Some clinical researchers suggest that periodontal probing be performed at infrequent intervals at one site (the same site each time) with light pressure. Any bone loss exceeding these averages should raise concern. sulcular brushes. but again. actinobacillus actinomycetemcomitans. transmucosal abutments. Increased probing depths have been correlated with failing implants. limiting the number of devices is important for patient compliance.gluconate mouthrinse can be very effective due to its substantivity (binding activity to the tissues in the oral cavity and on titanium abutment surfaces). the use of a nonmetal periodontal probe will not contaminate the titanium surface. Although 3 mm is considered healthy for natural dentition. After the soft tissue has been examined. and irrigation devices are all alternative secondary mechanical plaquecontrol aids. releasing chlorhexidine gluconate over a prolonged period of time in concentrations sufficient to maintain bacteriostasis. and prosthetic Crest Oral-B at dentalcare.

recent studies acknowledge its limitations such as overestimating the vertical distance between the top of the implant and the crestal bone. Ultrasonic instrumentation continues to be contraindicated with dental implants. resulting in corrosion. or tin-oxide. Although air polishing on implant surfaces was controversial in the past. Radiographic images can assess bone height and density and show the functional relationship between the prosthesis.com Continuing Education Course. The modified ultrasonic instrument produced noticeable but minimal changes that when polished did not appear to be microscopically different from the polished control. comparing the number of human gingival fibroblasts attaching to the surface of a commercially pure titanium-alloy curette. A mobile implant may display a narrow. In commercial use and form. Revised March 6. Rubber cup polishing alone appears to be the least abrasive treatment using a prophylaxis paste. 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. graphite. pure titanium is soft. radiolucent space surrounding the implant-bone interface. It is the most reliable of all the conventional periodontal indices for evaluating failing implants. only instruments that do not damage the implant surfaces may be used. However. radiographic images should be taken once each year. commercial implant pastes. Damage can lead to changes in the surface chemistry of the material. In the last few years. professional oral prophylaxis is required to maintain a healthy oral environment. ultimately compromising the implant. 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. The use of these dissimilar metals on implant surfaces have been studied in vitro. The occlusion should be monitored at recare appointments to detect occlusal changes. Crest Oral-B at dentalcare. and abutment components. After calculus deposits have been removed. implant. cause considerable changes to the implant surface. A rubber point may also 7 Debridement In addition to regular self-care procedures. Shallow scratches made with the metal ultrasonic could be polished smooth. The modified ultrasonic instrument may be a promising device for maintenance of the dental implant. Surface roughness and corrosion facilitate plaque retention. non-magnetic. Ultrasonic scalers may severely disrupt the titanium dioxide surface. which can lead to further plaque retention and a compromised implant. The use of a dissimilar metal (such as stainless steel) on titanium may lead to corrosion. as well as being utilized in post-operative imaging. It is therefore imperative that no oral health maintenance procedure directly affect this titanium oxide surface layer. However. recent studies have shown air polishing to be effective and safe for maintenance procedures. or those with a Teflon®coating should be in contact with the implant. but the deeper scratches could not. Possibly the most important evaluation tool to evaluate the health and success of the implant is dental radiographic images. 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. and passive. No definite answer can be made concerning ultrasonic use for implants at this time. a periodic. Seventy-eight percent of failing implants have excess mobility. For dental implant plaque and calculus removal. leading to a multitude of grooves and a roughened surface. These metallic surfaces develop a layer of titanium oxide that does not undergo any further breakdown under physiologic situations. and pocketing. 2013 ® ® . the prosthesis and abutments may be selectively polished with a rubber cup and a nonabrasive fine polishing paste. nylon. alveolar bone loss. Only instruments made of plastic. cone beam computed tomography (CBCT) has been used for measuring cortical bone thickness.superstructure. 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. Conventional metal curettes. paste deposits will be left on the implant surfaces. Professional dental prophylaxis is essential in every periodontal maintenance case. as well as sonic and ultrasonic scalers. After the first year.

To achieve long-term success. During the first two years. no more than six months should elapse between recare visits. a three- month recare schedule is suggested for a one-year duration.. These systems contain a tetracyclineloaded fiber that is designed to slowly release the antibiotic over a ten-day period.) motivation to perform consistent self care and the patient’s manual dexterity. the clinician reviews the adequacy of self care procedures and re-evaluates the health of the peri-implant tissues. At this appointment. A strict prophylaxis recare schedule should be established and maintained to monitor the oral health findings in dental implant patients. bleeding. After the one month follow-up. the implant surfaces should be gently irrigated with water to avoid any adverse tissue healing. and other factors such as patient habits (i. the patient may then be placed on a six-month recare schedule after the first year. can be applied. An antimicrobial solution should be applied to the peri-implant tissues. To ensure optimal peri-implant health.be used. location and angulation of the implants. Inc. and implant health. 2013 ® ® . The fibers can be used in single or multiple sites and may provide additional benefits to conventional scaling and root planing. the length and the position of the transmucosal abutments.com Continuing Education Course. Conclusion The dental professional’s role is to determine the dental implant patient’s individual and specific self care needs. The patient is often seen for comprehensive oral hygiene instructions and soft-tissue examination within the first week after the prosthesis is placed. or any other indication of the onset of failure. A follow-up visit is scheduled for one month later. smoking. If a dental implant is displaying increased probing depths. it is important to maintain a prophylaxis recare schedule at which evaluations are performed to assess gingival. the patient must maintain daily biofilm removal and maintain regular professional care. Recommendations and instructions to patients are often determined by the prosthesis design. Depending on patient self care and the individual’s periodontal status. After polishing. 8 Crest Oral-B at dentalcare. a controlled drug delivery system.e. bone. such as Arestin® by OraPharma. It is important to recommend individualized auxiliary aids to gain and maintain appropriate self care and compliance. Revised March 6.

4. c. No single technique Studies indicate that when multiple oral hygiene devices are prescribed. may become discouraged and less motivated b. should be _______________. Fones b. rapidly / larger d. metal to remove all debris from implant b. Plaque develops more __________ and in __________ amounts around titanium implant abutments than around natural teeth. Charter’s When cleaning an implant. The frequency of professional recare visits d.Course Test Preview To receive Continuing Education credit for this course. a. Threading systems d. 2013 ® ® . a. a. slowly / larger _______________ has been shown to best remove plaque from all surfaces of an implant. 6. 7. The dental implant can be compromised if the titanium oxide layer of the implant is disrupted. overwhelmed and stop self care completely The _______________ technique is the preferred toothbrushing method for dental implants. plastic coated d. rapidly / smaller c. 5. Using power toothbrushes The peri-implant disease process resembles periodontitis. Revised March 6. oral hygiene auxiliary devices. Brushes b.com and find this course in the Continuing Education section. _______________ is the major factor in determining long-term prognosis of the dental implant. Modified Bass c. b.dentalcare. The first statement is true. Modified Stillman d. Both statements are true. The second statement is true. a. at one time. a. 3. a. the patient _______________. slowly / smaller b. overly zealous with home care d. a. you must complete the online test. including scalers and periodontal probes. Both statements are false. 1. may become more motivated and encouraged c. d. Please go to www. titanium 2. The second statement is false. made from same material as the implant c. The first statement is false. 9 Crest Oral-B at dentalcare. Floss c. The mucoperiosteal-implant seal b.com Continuing Education Course. Using the high-speed handpiece during the procedure c.

remove the implant before more damage is done c. radiographs c. a.8. see the patient on a weekly basis until condition is under control 10 Crest Oral-B at dentalcare. probing depths d. the lack of fiber barriers between the implant and the soft tissue of the sulcus c. plant alkaloids d. Gingivitis around dental implants most likely progresses to periodontitis due to _______________. 2013 ® ® . the clinician should _______________. a. chlorhexidine gluconate b. rarely 14. never b. phenolic compound c. or other indications of the onset of failure.5 c. the unreliability of the perimucosal seal b. have the patient step up home care maintenance to three times a day b. bleeding. usually c. bacteriostasis c. As a rule. 10. 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 _______________. 6 12. tetracycline 9. Revised March 6. osteolytic d. a. lack of patient knowledge d. always d. the ideal sulcus depth around a dental implant should be no more than _______ mm. a. 5 d. If an implant is displaying increased probing depths. tissue tone 13.com Continuing Education Course. a. The most important evaluation tool and the most reliable method to determine implant failure is _______________. osseointegration The mouthrinse containing _______________ aids in the fibroblast attachment to implant surfaces. mobility b. Ultrasonic instrumentation should ____________ be used with dental implants. apply a controlled drug delivery system d. A and B 11. a. bacteremia b. 2 b. 2. a.

All of the above. A strict prophylaxis recare schedule should be established and maintained to monitor oral health findings in implant patients.15. six 16. removal of early microbial accumulation b. and no more than __________ month(s) should elapse between oral hygiene/recare visits. 17. three c. a. improved speech and mastication c. improved placement techniques b. 60 / 2 20. such as _______________. oral health motivation c. 90 / 5 b. a. a.com Continuing Education Course. a. regular use of chemotherapeutic mouthrinses d. the dental professional must determine the patient’s individual and specific self care needs. manual dexterity d. A 30 second rinse of 0. Revised March 6. surgical removal of any inflamed tissue b. All of the above. All of the above. regular use of systemic medication 19. The _______________ is/are crucial for long-term peri-implant success. Treatment of both adult periodontitis and peri-implantitis may begin with effective microbial plaque removal and _______________. 70 / 3 d. one b. prophylaxis recare schedule to assess gingiva and bone health d. yearly in-office prophylaxis c. improved patient confidence and self esteem d. elimination of at least 85% of plaque biofilm c. 11 Crest Oral-B at dentalcare. To ensure optimal peri-implant health. 80 / 4 c. 2013 ® ® . 18. a. An increase of dental implants has risen greatly due to _______________. a. habits such as smoking b.12 percent concentration of chlorhexidine can inhibit _______ percent of the cultivable bacteria for approximately _______ hours. twelve d.

3rd Edition. Dental implants in periodontal therapy. 16. 10. Becker W. Implant Dent. 648. 646. 2012. 4. 7.52(12):810-811.5(1):47-52. 14-25. Kishida M. Int J Oral Maxillofac Implants. Kusy RP. J Dent Res. Implant maintenance: debridement and peri-implant home care. 2007. 25. Louis. 13. American Academy of Periodontology. Bauman GR. 2000 Dec. Swan RH. Hallmon WW. 12 Crest Oral-B at dentalcare. J Dent Hyg. 1985. Committee on Research. Tissue-Integrated Prosthesis Osseointegration in Clinical Dentistry. 2nd Edition.4(4):305-310. Ito K. 8. Saunders: Maryland Heights. Int J Oral Maxillofac Implants. Albrektson.61(8):491-496. Peri-implant considerations.51(3):729-737. 424-425. Papaspyridakos P.108(5):21-23. 11. Contemporary Implant Dentistry. American Academy of Periodontology. Rapley JW. Brough Muzzin KM. 1988 Dec. Orton GS. Moriarty JD. Maintenance and Treatment of Dental Implants [position paper]. Smith RA. Biesbrock AR. Kwan JY. 12. and gingival health: a two-month clinical trial with antimicrobial agents. Johnson R. World Dental 3:17-19. Daffron P. 18. Gerlach RW. American Dental Assistants Association. 2012 Mar. 2. Terézhalmy GT. 15. Meffert RM. Morgese F. The surface characteristics produced by various oral hygiene instruments and materials on titanium implant abutments.12(9):644. Bartizek RD. Babbush CA et al. p. Mosby: St.60(1):54-59.61(8):485-490.78(9):1689-1694. The soft tissue interface in dental implantology. 1986 Feb. Yagi H. Mioduski TE Jr. The effects of scaling a titanium implant surface with metal and plastic instruments: an in vitro study. The Art and Science.62(9):448-453. et al. 2013 ® ® . Kracher CM. Ill Dent J. Kracher CM. J Clin Dent. 1991 Jan-Feb. The dental hygienist’s role in the maintenance of osseointegrated dental implants. 1990 Nov-Dec. Kerner J. 5. Hygiene maintenance procedures for patients treated with the tissue integrated prosthesis (osseointegration).64(9):422. Guinn NJ.Part 2. Oral hygiene for dental implant patients. 1990 Mar. Steele DL. Squillace A. Comp Esthetics & Restor Prac May 2005. Implants: hygiene maintenance of dental implants. Chen CJ. Implant maintenance using a modified ultrasonic instrument. Mills MP. J Periodontol. Becker BE. Continuing Education: Current Concepts in Preventive Dentistry. Hallmon WW. Peri-implant Postoperative Treatment Considerations to Prevent Peri-implantitis. 1989 Winter. J Periodontol. April 1995. 20. Tex Dent J. 24. Dental professional’s role in monitoring and maintenance of tissueintegrated prostheses. Dent Clin North Am. Chicago. Branemark. Success criteria in implant dentistry: a systematic review. Nyman S. Meffert RM. 26. Nimmons KJ. Ramaglia L.91(3):242-248. 23.References 1.71(12):1934-1942. Dental Implants. Wolinsky LE. 430. Treatment of titanium dental implants with three piezoelectric ultrasonic scalers: an in vivo study. Matsumoto K. The effects of scaling titanium implant surfaces with metal and plastic instruments on cell attachment.18(4): 101-105. Science and Therapy. Fox SC. 17. Profilometric and standard error of the mean analysis of rough implant surfaces treated with different instrumentations. Compendium. 2007 Sep. 2008. 22.24(3):415-420. 2006 Mar. 2011.17(2):95-102. 29. 14. Fox SC. The Expanding Esthetic Practice: Implant Maintenance . J Periodontol. Clinical and microbiologic findings that may contribute to dental implant failure. Koumjian JH. Kawashima H. Rapley JW. Zarb.15(1):77-82. Carr P. 9. 1991 May. AORN J. Newman MG. 1990 Aug.5(1):31-38. di Lauro AE. Zablotsky MH. Int J Oral Maxillofac Implants. Dmytryk JJ. MO. Revised March 6. Oral hygiene regimens. 1990 Spring.com Continuing Education Course. J Dent Educ.2-5. 19. 1990 Spring. Mills M. 21. 1990 Aug. Iacono VJ. Balshi TJ. Quintessence. Misch CE. May-June 2011. 1988 Oct. Singh M. 1980 Jul. MO. J Periodontol. 6. J Dent Hyg. 3. Moriarty JD. Friedman LA. Sato S. James RA. plaque control. 1991 Sep. Permanent replacement for lost teeth. Dental implants. Quintessence Int.

35. 33. A Color Atlas. Dr. Accuracy of measuring the cortical bone thickness adjacent to dental implants using cone beam computed tomography. Davies J. Ito K. 2010 Jul. Chuang SK. 28. PSG. “Blood Pressure Guidelines and Screening Techniques” and “Current Concepts in Preventive Dentistry”. J Clin Periodontol. Renvert S. USA. Daher S. 31. 1-24. She holds a PhD from Lynn University in Boca Raton. 1985. 2013 ® ® . Kyiyaku EuroAmerica. The Branemark System of Oral Reconstruction. Lessem J. Kracher. Indiana. Email: kracher@ipfw.com Continuing Education Course. Razavi T. Corrosive response of the interface tissue to 316 L stainless steel.32(2):355-370. Inc. et al. Quintessence Books. 13 Crest Oral-B at dentalcare. Van Steenberghe D.27. BSEd Wendy Schmeling Smith received her baccalaureate degree in education from Indiana University – Purdue University Indianapolis. Palmer RM. 30. Clin Oral Implants Res. J Oral Implantol. and the Chair of the Department of Dental Education at Indiana University . She is a licensed dental hygienist in private practice in Indianapolis. a Master of Science in Dentistry from the Indiana University School of Dentistry in Oral Biology. Director of the Dental Assisting Program. 2006 May. 32. Muftu A. 2009. and a Bachelor of Science from Indiana University – Purdue University Indianapolis. Topical minocycline microspheres versus topical chlorhexidine gel as an adjunct to mechanical debridement of incipient peri-implant infections: a randomized clinical trial. Kracher is an Associate Professor of Dental Education. Vehemente VA. The comparative effect of ultrasonic scalers on titanium surfaces: an in vitro study. Fort Wayne. About the Authors Connie M. 34. RDH.21(7):718-725.Purdue University. Clinical Practice of the Dental Hygienist. Revised March 6. Philadelphia:Lippincott Williams & Wilkins. Risk factors affecting dental implant survival. Florida. Van Orden AC. Dodson TB. 2nd edition. PhD. Littleton. Dental Implants: Are They for Me? 1993.75(9):1269-1273. Lemons JE (eds) The Dental Implant: Clinical and Biological Response of Oral Tissues. Palmer PJ. Periodontal aspects of osseointegrated oral implants modum Brånemark. 10th edition.edu Wendy Schmeling Smith. In addition to her CDA. and cobalt based alloys. Sato S. Kishida M. Rasmussen RA. Taylor TD.28(2):74-81. Kracher is a frequent contributor to the Dental Assistant Journal and is the author of four ADAA courses: “Sports Related Dental Injuries & Sports Dentistry”. 1988 Apr. Dahlén G. MSD Dr. 2002. 29. 1992.33(5):362-369. Wilson R. 2004 Sep. titanium based alloy. Wilkins EM. Wyche C. In: McKinney RV. Dent Clin North Am. MA. she holds a Certificate in Expanded Restorative Procedures (EFDA). J Periodontol.