Learning Objectives • The importance of caring for implants and dentures. • How to care for implants and dentures. • What types of homecare products our patients can use to care for their implants and dentures.
Implant Background • In the 1950s, in Sweden, Dr. Branemark discovered that titanium integrates with bone while working on a rabbit and name this fusion osseointegration. This invention was an accident! • In 1965, the first titanium implant was placed on a patientin Sweden. • In 1982 the FDA approved titanium implants in the U.S.
Statistics • 69% of adults ages 35-44 have lost at least 1 permanent tooth from tooth decay, gum disease, failed root canal, or trauma. • By the age of 72, 26% of adults have lost all their permanent teeth. With that said…. • Dental implants are the best restorative option for those who are missing teethand have adequate bone support. • When an implant is in place, the titanium fuses with the bone in which act like a real tooth.
Types of dental implants: • Single tooth implants • Full-arch rehabilitation
Why is dental implant care so important? • There is a risk of implant failure. 2 classifications of infections: • Peri-implant mucositis: a reversible inflammation of peri-implant mucosa without bone resorption. • Peri-implantitis: an irreversible bone resorption process.
From the International Journal of Dental Hygiene: Clinical evaluation of an implant maintenance protocol for the prevention of peri-implant disease in patients treated with immediately loaded full-arch rehabilitation. By: S Corbella, M Del Fabbro, S Taschieri, F De Siena, and L Francetti Purpose: The intent of the study was to assess an implant maintenance protocol in patients who received full-arch prosthesis combined with both straight and tilted implants according to an immediate loading protocol. Materials: 61 patients were conducted for this study and 244 implants were analyzed. • Each patient was evaluated via probing exams, bleeding and plaque indexes, and radiographs every 6 months for 2 years and then yearly after that. Patients received professional cleanings at each visit and also were given specific oral hygiene home-care instructions to follow. Results: Peri-mucositis was less then 10% at each check up and only 3 implants were lost due to per-implantitis. • Plaque and bleeding scores decreased at each visit and the probing depths were stable (even at the 5 year check up) • The procedure: • Before surgery– chx was prescribed for 1 min twice a day for 3 days • After surgery they rinsed for 1 min 3 times a day for 3 days • There were told to use soft bristle toothbrushes, interdental brushes, spongy interdental floss throughout their care. Conclusion: This study proves the importance of having patients with implants comply with a proper home care program as well as coming in for professional care. In doing so, the risk of implant failure is significantly reduced.
Home Care Guide • Soft bristle toothbrushes or power brushes:Emphasize SOFT bristles because hard bristles can damage the abutment part of the implant and allow for plaque biofilm accumulation and crown portion or can cause recession. Recommend a 45 degree angle towards the gum line. -Recommended use: 2-3 times daily
Home Care Guide • Unituft interspace brush (tapered or flat)-This allows the client to work on one tooth at a time. This brush is designed to get into the hard-to-reach areas and remove plaque biofilm and it also strengthens the gingival tissue surrounding the dental implants. Soft bristle nylon coated will not hurt the implant. Recommended use: 2-3 times daily • Rubber tip: removes debris and plaque biofilm and also stimulates or massages the gingival tissue surrounding the implant. Recommended use: once daily
Home Care Guide Interdental brushes (nylon coated) -Can be used to access hard-to-reach areas especially interproximal and should be discarded when the nylon is worn down to the metal wire.Recommended use: once daily Dental floss and dental tape :used to clean interproximal areas of the dental implants and removes plaque biofilm. This can be used in conjunction with a floss threader. -Recommended: 1x daily • Tie floss around implant, crisscrossed, and pull in a shoe-shining motion to clean the abutment.
Home Care Guide • Dentifrice: a non-abrasive dentifrice. An abrasive dentifrice can scratch the implant in which plaque biofilm will be able to adhere easily to. • Ex: Crest-Pro Health and Colgate Total are safe • Oral irrigator (WaterPik) can be used on the LOWEST setting where a patient is experiencing inflammation surrounding the dental implant.
Home Care Guide • Antimicrobial agent: should be used 5-7 days after the implant is placed and when necessary. A capful of 0.12% chlorhexidine gluconate solution is used for 30 seconds twice a day to help with the plaque biofilm accumulation and peri-implant diseases. Every dental implant aid can be dipped into chlorhexidine before use. Ex: interdental brush
Home Care Guide • Crevitec Plus varnish with chlorhexidine gluconate can be used to protect peri-implant tissues. Active Ingredients: 1% chlorhexidine and 1% thymol present in this varnish firmly adhere to the implant and form a shield around the implant.
Professional Care When working on a patient with a dental implant, it is extremely important to use plastic coated or Teflon-coated instruments to avoid scratching the implant which can lead to plaque accumulation and disease. • Gold-tipped Graceys are designed for implant use. • Powered devices (ultrasonic)- special tips that don’t damage implants made with nonmetallic plastic or carbon tips. Studies show more effective then plastic hand-scalers! At each visit…. • Make sure to probe! • Assess gingival tissues for any signs of inflammation, color changes, bleeding, exudate, and recession. • Patients with implants should be on a 3-4 month(or as needed) continued-care plan.
ContraindicationsFor Implants • Scaling or probing with metal instruments • A highly abrasive dentifrice • A hard bristle toothbrush • Chlorhexidine if used with a dentifrice containing SLS or fluoride. • Don’t coronal polish! –This is too abrasive for the crown of the implant.
Dentures Dentures are a removable replacement for missing teeth and surrounding tissues Complete dentures- when all the teeth are missing Partial dentures- when some natural teeth remain
Denture History 700BC-Etruscans in northern Italy made dentures out of human or other animal teeth. These deteriorated quickly but, being easy to produce, were popular until the mid-19th century. 1700-The first porcelain dentures were made. 1850s- Dentures made of a form of hardened rubber 20thCentury- Acrylic resin
Denture care Improperly cleaned dentures is a reservoir for microorganisms. Pathogens, in combination with other risk factors, may be associated with oral and systemic diseases. Denture stomatitis: painful infection and sores caused by not removing dentures at night and from improper denture cleaning. Proper denture care: Always fill the sink with water or place a folded towel in the sink and never use hot water! Brush all surfaces and rinse dentures daily with a denture brush and denture paste. Removing dentures at night soaking them in a immersion dental cleanser/ disinfectant.
Brush dentures daily Dentures must be brushed daily • to remove food and plaque • prevent the development of permanent stains • Reduce odor Denture Brush-a soft bristle brush, indicated and safely designed for cleaning dentures. Recommended use: 2-3x daily Denture Paste-Specifically designed, low abrasivetydentifrice used for brushing dentures. • Ordinary toothpaste is contraindicated with dentures because the abrasives scratch the acrylic leaving areas for bacteria to hide. • Ingredients: Dicalcium phosphate dihydrate, propylene glycol, calcium carbonate
Denture care when not being worn • Immersion dental cleansers-Tablets dissolved into water used to soak dentures overnight. • Dentures need to be kept moist when not being worn so they do not dry out or lose their shape. • Dentures should never be placed in hot water, as it can cause them to warp and fit improperly. • Immersion cleansers are indicated and safe for all dentures. • Recommended use: nightly • Active Ingredients: Sodium bicarbonate, citric acid, sodium perborate, sodium polyphosphate, potassium monopersulfate
A Clinical And Microbiological Evaluation of Denture Cleaners for Geriatric Patients in Long-Term Care Institutions.Gornitsky M, Paradis I, Landaverde G, Malo A, Velly A • A study conducted by the Reasearch and Ethics committees of the Sir Mortimer B. Davis Jewish General Hospital compared the efficacy of 3 immersion type denture cleaners aimed to reduce the levels of Candida spp. and Streptococcus mutans found on the dentures of hospitalized geriatric patients. • 27 geriatric patients participated and were separated into 4 study groups. • Each study group received 1 of the 3 dentures cleansers (Denture Brite, Polident, and Efferdent) or water (control). • Ultrasonic bath, for 5 minutes, one week prior to using the cleaner standardized the initial amount of bacteria. • For a total of 35 days, the cleaners were used for three 7 day intervals (21 days total) separated by 7 day intervals of water only (14 days total). • Culture swabs were collected from the palatal surface of the patient’s upper denture on days 1, 8,15,22,29, and 36 and sent to the University of Montreal Bacteriology department to be evaluated for colony forming units (CFUs) of the bacterial produced. The number of CFUs produced in before cleanser cultures were compared to the number of CFUs produced in after cleanser culture by means of a general linear model. • Immersion type denture cleansers significantly reduce levels of harmful bacteria, Candida spp. and Streptococcus mutans, on dentures in hospitalized geriatric patients when compared to just water alone.
iSonic Ultrasonic Denture Cleaner • Study by University of Sao Paulo, Brazil shows that a combination of an ultrasonic cleaner and immersion cleansing tablets increased effectiveness in removing of microorganism and debris from dentures. • We can recommend our patients to use ultrasonic cleaner at home! • Use tap water • 5 min auto shut off • Safe to use with cleaning tablets or solution.
The Effect of Denture Cleansing Solutions on The Retention of Yellow HaderClips: An In Vitro Study • Purpose: An in vitro study was designed to test yellow Haderclips retention on implant over dentures after soaking into various denture cleansers. • Method: The 18 yellow Hader clips were divided into seven testing groups, placed in perforated plastic bags, and immersed into Polident Regular, Polident Overnight, Efferent, 5.25% Sodium Hypochlorite (NaOCl, 1:10 dilution) 15 min/day, NaOCl (1:10 dilution) 8 hours/day, water and dry (control group) for a equivalent time of six months. After the period of soaking, the yellow Hader clips were tested for its retention with a Universal Testing Machine set under 2 inches per min to stimulate in vivo snap removal. • Results: Denture cleansing solutions have significant effect on yellow Hader clip’s retentive. • Conclusion: It is not recommended to use Sodium Hypochlorite 1:10 dilution 15 min/day as denture cleansing solution because it causes the clips to be rigid and easily fracture or break. All other cleansing solutions had little affect on the retentive value, so they were safe to use.
Denture Adhesive • Denture adhesive entered dentistry at end of 18th century. • 1980’s Zinc were added • Fixodent and Poli-Grip: 17-34 mg/g of Zinc • Higher than level that USDA recommended of 8-11mg/day.
Zinc and Medical Problems 2005, FDA received reports of zinc poisoning secondary to Poligrip denture adhesive cream. 2008 University of Texas Southwestern Medical Center published research linking denture cream to zinc poisoning in The Medical Journal Neurology. 2009 medical research confirmed that denture cream is a primary source of excessive zinc. Excessive levels of zinc causes a copper deficiency, myelopathy and neuropathy.
Zinc and Medical Problems • Copper deficiency leads to impaired iron mobilization, anemia, leukopenia, neutropenia, increase plasma cholesterol, and abnormal cardiac function. • Neuropathy can result to permanent disability, paralysis and even death. • Symptoms of neuropathy included: Tingling, numbness, burning, and pain in the extremities. Paralysis, muscle weakness, poor balance and coordination Abnormal blood pressure and heart rate Constipation and bladder dysfunction Decrease in walking stride.
Fixodent Zinc Contain Neutral No Zinc Added Active ingredients: polymethyl vinyl ether-maleic anhydride (PVM-MA) zinc and calcium salts with carboxymethylcellulose. How to apply: 3-4 pea-size amounts throughout denture, keeping away from the edges.
Secure Waterproof Denture Adhesive • Will not washed away by liquids or saliva. • Bonding last up to 12 hours. • Manufacture gives the wrong advice to leave denture on overnight if it still adheres. We want our patients to avoid denture stomatitis!!
Quiz • Osseointegreation was discovered on a hobbit. This was not an accident. • A. The first statement is true, the second statement is false. • B. Both statements are true. • C. Both statements are false. • D. The first statement is false, the second statement is true.
Quiz • Excessive level of zinc cause following medical problems except: A. Copper Deficiency B. Potassium Deficiency C. Neuropathy D. Myelopathy
Quiz • Denture stomatitis is a genetic disorder. Dentures should be worn at all times. • A: The first statement is true, second statement is false. • B: Both statements are true. • C: Both statements are false. • D: The first statement is false, and the second statement is true.
References • Noblebiocare[Internet]. Switzerland: Sept 21, 2010. [Mar 10, 2013]. 1 page. http://corporate.nobelbiocare.com/en/our-company/history-and-innovations/default.aspx • Corbella S, Fabbro MD, Taschierri S, et al. Clinical evaluation of an implant maintenance protocol for the prevention of peri-implant diseases in patients treated with immediately loaded full-arch rehabilitation. Int J Dent Hyg 9. 2011; 216-222. • Darby ML, Walsch MM. Dental hygiene theory and practice. 3rd ed. St. Louis: Elsevier, Saunders; 2010. p 1100-1110 • Miro AP, Geist ET, Nelson WJ, et al. Dental implants. [Internet]. Rosemont, IL:American Association of Oral and Maxillofacial Surgeons; 2008-2012. http://www.aaoms.org/dental_implants.php • IvoclarVivadent. Crevitec [Internet].Amhert, NY: IvoclarVivadent; http://www.ivoclarvivadent.us/en/competences/all-ceramics/prevention-care/cervitec-plus • Nield-Gehrig JS. Fundamentals of periodontal instrumentation and advanced root instrumentation. 7th ed. Baltimore: Lippincott William & Wilkins; 2008. P 652. • Weber HP, Morton D, Gallucci GO, et all. Consensus statement and recommended clinical procedures regarding loading protocols. Int J Oral Surg 24, 2009; 180-183. • James J Sciubba, DMD, PhD; Chief Editor: Dirk M Elston, MD. Denture Stomatitis [Internet]. Medscape Reference; 2012 Jan [cited 2013 March]. Available from: http://emedicine.medscape.com/article/1075994-overview • Tonn E, DDS. Caring for Dentures[Internet]. WebMD; 2012 May [cited 3013 March]. Available from:http://www.webmd.com/oral-health/guide/caring-dentures • GornitskyM, Paradis I, Landaverde G, Malo A, Velly A. A Clinical and Microbiological Evaluation of Denture Cleansers for Geriatric Patients in Long-Term Care Institutions. J Can Dent Assoc. 2002; 68: 39-45.
References 11. Varghese RM, Masri R, Driscoll CF, Romberg E. The effect of denture cleansing solutions on the retention of yellow hader clips: an in vitro study. Journal of Prosthodontics. 2007 Jun; 16(3):165-171. 12. Angrade IM, Cruz PC, Silva CHL, Souza RF, Paranhos HFO, Candido RC, Marin JM, Souza-Gugelmin MCM. Effervescent tablets and ultrasonic devices against Candida and mutans streptococci in denture biofilm: Gerodontology. 2011 Dec;28(4)264-270. 13. Bedbathandbeyond.com: isonic ultrasonic denture/retainer cleaner. [Internet][cited 2013 Feb 16]. Available from: http://www.bedbathandbeyond.com/product.asp?sku=41049280&utm_source=google&utm_medium=cpc&gclid=CPu4k8j4vLUCFYFxQgodayoA3A 14. Gupta R. Luthra RP. Denture adhesives: A Review. Indian Journal of Dental Sciences. 2012 September;4(3) 15. Dentureliving.com: brought to you by fixodent [Internet]. Procter & Gambel (P&G). [cited 2013 Feb 16]. Available from: http://www.dentureliving.com/fixodent-denture-products/denture-adhesives 16. Goodguide.com: fixodent control denture adhesive cream plus scope flavor [Internet][cited 2013 Feb 16]. Available from: http://www.goodguide.com/products/208257-fixodent-control-denture-adhesive 17. Seciredemture.com: Secure zinc-free plus 12-hour holding power. Denture adhesive and denture cream. [Internet][cited 2013 Feb 16]. Available from: http://www.securedenture.com/Secure-Denture-Bonding-Cream.aspx 18. Images: google.com