We are switching it up this week and bringing you a tip from Michelle. She has a huge course on maintaining dental implants in-office and at-home and for some reason hasn’t shared that info with you guys. This week she has some tips on how to assess a dental implant and when you should scale one.
She is a big fan of the facebook group, Dental Implants Uncovered. If you want to learn more about how to maintain these awesome appliances that give people another chance at teeth, head over to that group.
You can find more info from Michelle at her website MIchelleStrangerdh.com where she has links to all of her articles
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This TIPisode has been transcribed for your viewing pleasure:
A Tale of Two Hygienists presents this week’s TIPisode: Quick and easy tips to keep you up to date and presented by the experts in the profession. Now, get ready for your unofficial TIPisode.
Hey, guys. So this is a little change. This is Michelle, and I’m here to do your TIPisode this week. I was encouraged to do this TIPisode because I have a huge course on dental implants and in-office maintenance and at-home maintenance, and I see a lot of misinformation out there about maintaining dental implants. And so I wanted just to take a minute to give you some of these quick tips.
I also encourage you — if you are seeing dental implants or you have any questions, there’s an amazing Facebook group out there called Dental Implants Uncovered. It’s a place where you can ask questions. It’s a safe place. We’ll be able to discuss, you know, what it’s like to actually see this type of implant and what would your next steps be. Such a great resource.
But my quick tips are going to be on assessment and when to touch the implant with a scaler. And you’re going to be like, “What do you mean? Am I not supposed to touch the implant with a scaler?” You’ll find out.
So, first, I want you to really understand that to determine an implant’s health or disease, it is multiple pieces of a puzzle. It’s not just probing depths. It’s not just radiographs. It’s a little bit of everything. They’re very different than natural teeth, and so we got to remember that these are medical devices placed in people’s jawbones. They are not natural teeth. And so the way we are going to maintain them and assess them are — it’s going to be different.
But, first, we’re going to take a look at the probing depths. Yes. Probing is important. And this is a much bigger conversation, so don’t let that stop here.
— probe, the pressures that we use, and those are really big components. So it’s always going to be a very, very light, light pressure. It is not the same as probing around natural teeth. It needs to be a very, very light pressure. They say about 25 newtons, which is very hard to understand and apply clinically, but just use more of an exploratory type of, you know, use of the probe. So it’s very gentle, almost like you’re looking for calculus with the explorer, but you’re going underneath that tissue with the probe.
But the AAP does recommend getting a baseline measurement after about a year. So, once that implant has a crown on top of it, you want to wait about one year to start making — or taking measurements. There’s a lot of controversy around that, but that is only the AAP’s guidelines. But a baseline is going to be very important.
And the reason we probe is for both qualitative data and quantitative data. So meaning, yes, we want to get a number, but we also want to look and see is there bleeding? Is there pus? What’s the tissue consistency? And, when we get that number, we can’t also put too much weight on that as well. It all is about the baseline measurement that the patient started with. So, once you were able to probe that implant with that crown on there, was it a four at that time? And then it’s a four three years later? No problem. But, if it was a two and then it became a four or if it was a three and now it’s a six, that’s a little bit more of a concern.
So there are implants out there that have a measurement of six millimeters just because that’s how the implant was placed. It had that thick, thick biotype, that thick keratinized tissue. There’s just — it’s just a deeper probing depth. But, if that was always the baseline, then it’s still considered healthy. It’s about bleeding, exudate, and any probing depths that change outside of that baseline measurement.
But you can still use plastic or metal. Just be consistent with what you’re using. So, if you’re always using plastic with that particular patient, always use plastic probes. If you’ve occasionally used metal, stick with the metal because then you won’t get your numbers and your measurements all over the place. But it needs to be a very gentle probing. And, if you don’t feel comfortable, find the training. Get help. Talk to your clinical team. Ask — you know, you’re referring — if you’re not the ones placing the implants, maybe you’re the ones that are maintaining it. Go talk to them. Make sure that you’re doing right by that dental implant and that you’re not penetrating that tissue.
But the upside is that if you do penetrate the tissue with the probe, it’s usually in the presence of inflammation. And it would be better to diagnose that inflammation than not use a probe at all for fear of puncturing that tissue. And it does tend to establish itself within about five days. That comes from a 2018 Ivanovski and Lee article and also a Heitz-Mayfield and Lang 2010 article. So they can reestablish that — or that puncture wound can reestablish itself in about five days because reality is these are very fragile seals around these implants.
But, you know what? If they were that fragile and they weren’t going to heal, we’d have death by tortilla chips constantly with these implants. I mean, how often would our patients be losing it because they got one strawberry seed stuck there? So, yes, they are very fragile, but don’t worry. You will not kill it by just one time accidentally puncturing that seal. So don’t worry.
Radiographs are going to be very important. It’s super important to get the baseline radiograph at the time of the placement of that superstructure, so that crown or bridge or any of the superstructures that are going on these implants. I prefer a PA because I could see a lot more information versus a bitewing, but that’s something that you should definitely talk to your doctor about and as a team come up with a consensus like, “We all always take one time a year, a PA.” Whatever works for you. But I personally take a PA every year.
And then visual assessment is going to be huge. Just look at it. What is – is it red? Is it inflamed? Does it have enough keratinized tissue?
Palpating is also really important meaning I put my finger on either side of that implant on the ridge, and I kind of just press on the bone. And I have actually found exudate more frequently doing that than just probing alone.
Your doctor might also want you to check for the contacts and occlusion. I’ve had doctors wanting me to do that in the chair, and I’ve had them coming in wanting to do it themselves. But making sure that the occlusion is good, that there’s no open contacts because if food gets impact [sic] between that natural tooth and the crown itself, there can be implant-induced decay on the natural tooth because it’s just packing so much food.
And then you also want to check for calculus and cement. Cement can be the death of a lot of implants, and you just want to make sure that there’s no roughness around that crown. And sometimes that’s because the crown’s not seated all the way, sometimes it’s calculus, and a lot of times it’s cement, and that’s the killer of a lot of implants.
And then, when we go to treat these implants, we ha — there’s been an [sic] never-ending conversation about what type of instruments. I think the science fully supports now that if you are going to touch the implant with a metal scaler, titanium is best. Softer Rockwell hardness, or lower Rockwell hardness, would be great to touch that implant. And, when you do touch an implant — I don’t care if it’s with titanium or not — you are changing that surface. You’re altering that surface in some way. So it would be great if we weren’t touching that implant unless we absolutely had to in order to remove hard deposit.
So, if it’s calculus, it does tend to come off a little bit easier. If it’s cement, that tends to take a little bit more time. It takes a lot more strokes and a lot more pressure against that implant to remove the cement, and we just know that that’s going to alter the surface, but we can’t leave it there because that will cause further disease.
But, if you’re just managing biofilm — let’s say this is a beautiful, healthy implant, it has had no attachment loss, you don’t see the abutment, and it’s just biofilm that we’re managing. Right now, I think if you don’t have the proper tools of an air-powder system like EMS or Acteon, then you can use a fine pumice, like something from Ivoclar. They have one that’s really low pumice, like a seven on the RDA. It’s called Proxyt. And you can just polish the implant and just do biofilm removal that way.
I personally use the glycine or erythritol powder because it is one of the only things that is not changing the surface of the implants. I know a lot of offices don’t have that. It seems like this new fancy equipment. Once upon a time I was calling that “best practices.” Like, if you had this in your office and you were able to do this AIRFLOW for EMS and then AIR-N-GO for Acteon, you were doing best practices. But, now, I really believe that that’s a standard of care. It’s here in the US. If you’re seeing implants enough, it’s worth investing in this equipment to make sure that you are not altering that medical device that’s implanted in somebody’s head.
So, if it’s biofilm management, I think erythritol and glycine are some of the best ways to disrupt that biofilm. If that’s not an option for you, using a fine pumice like Proxyt from Ivoclar. And, if you do have exposed root surface — or threads, then, yeah, that’s the same thing goes, you know, for just doing biofilm management.
If you have to take a scaler to that implant, remember titanium is best. And lavage is great, but making sure that you’re using ultrasonic instruments that are hopefully titanium like the piezo’s tips that are out there that are titanium. But it’s going to be really difficult to get that ultrasonic down into that sulcus without touching the implant, so I would just proceed with caution.
But this is also a great thing to add if you have that question, you’re like, “This is what I have as far as equipment. This is the type of patient that I’m seeing,” and putting that in that Facebook group called Dental Implants Uncovered. They’re a really fantastic resource.
You can definitely check out a lot of the articles that I have written about dental implant maintenance in office and at home. I think the home care is a huge part, and if we are seeing somebody with calculus where we’re always having to put that titanium scaler to the implant itself, then we really need to beef up that at-home maintenance. And so that’s going to look different for everyone. I have lots of articles about that. You can actually head to my personal website, michellestrangerdh.com, and click “articles,” and you’ll find some of those there.
And, of course, continue to follow the podcast. Thank you so much for any time that you share the episodes. If you learned something, tell your friends. We have grown this podcast organically because of you guys, and we really do appreciate that. We appreciate you. And I hope everyone has a wonderful holiday and a happy new year. Thank you, again, for taking the time listening to this TIPisode, and continue enjoying the podcast.
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